Transnational Mobility and Global Health: Traversing Borders and Boundaries

Transnational Mobility and Global Health

Transnational Mobility and Global Health spotlights the powerful and dynamic intersections of human movement, inequality, and health. The book explores the interacting political, economic, social, cultural, and climatic drivers of health and migration, proposing innovative ways to enhance global health and care provision in an era of transnational mobility. As health security continues to rise up the agenda in international politics, the book also analyses the political determinants of health and migration. Within the framework of key drivers of unequal mobilities, this book treats interconnected health and migration themes not covered elsewhere under one cover: health tourism, conflict-induced and other vulnerable-population movements, humanitarian crises, human rights, the health-development linkage, migranthealth-care, and health-competency education. The book also considers global health vulnerabilities in the wake of climate change, and the biomedical, ethical, and governance challenges of emerging and reemerging infectious diseases. Finally, the book suggests ways of evaluating mobility-influenced health outcomes and equity impacts, and explores how the global circulation of health expertise could help to rectify care- provider shortages. The challenges to global health considered in this book are only likely to become more intense as the 21st-Century surge in transnational migration continues. Readers will gain interdisciplinary appreciation for the relevance of health for migration and of migration for global health. Researchers, students, practitioners, and policy makers interested in individual and population health, sustainable development, and migration studies will find this book a useful and inspiring guide to contemporary global challenges. Peter H. Koehn is Professor of Political Science, Director of the Global Public Health program, and a Distinguished Scholar at the University of Montana, USA, a Fulbright New Century Scholar, and recipient of the Association of Public and Land Grant Universities’ (APLU) 2011 Michael P. Malone award for international leadership.

Routledge Studies in Development, Mobilities and Migration

This series is dedicated to the growing and important area of mobilities and migration within Development Studies. It promotes innovative and interdisciplinary research targeted at a global readership. The series welcomes submissions from established and junior authors on cutting-edge and high-level research on key topics that feature in global news and public debate. These include the Arab spring; famine in the Horn of Africa; riots; environmental migration; development-induced displacement and resettlement; livelihood transformations; people-trafficking; health and infectious diseases; employment; South-South migration; population growth; children’s well-being; marriage and family; food security; the global financial crisis; drugs wars; and other contemporary crises. A Gendered Approach to the Syrian Refugee Crisis Edited by Jane Freedman, Zeynep Kivilcim and Nurcan Ozgur Baklacıog˘lu South-South Migration Emerging Patterns, Opportunities, and Risks Edited by Patricia Short, Moazzem Hossain and M. Adil Khan Living with Floods in a Mobile Southeast Asia A Political Ecology of Vulnerability, Migration, and Environmental Change Edited by Carl Middleton, Rebecca J. Elmhirst and Supang Chantavanich Undocumented Migrants in the United States Life Narratives and Self-Representations Ina Batzke Transnational Mobility and Global Health Traversing Borders and Boundaries Peter H. Koehn For more information about this series, please visit: www.routledge.com/RoutledgeStudies-in-Development-Mobilities-and-Migration/book-series/RSDM

Transnational Mobility and Global Health Traversing Borders and Boundaries

Peter H. Koehn

Routledge Studies in Development, Mobilities and Migration

This series is dedicated to the growing and important area of mobilities and migration within Development Studies. It promotes innovative and interdisciplinary research targeted at a global readership. The series welcomes submissions from established and junior authors on cutting-edge and high-level research on key topics that feature in global news and public debate. These include the Arab spring; famine in the Horn of Africa; riots; environmental migration; development-induced displacement and resettlement; livelihood transformations; people-trafficking; health and infectious diseases; employment; South-South migration; population growth; children’s well-being; marriage and family; food security; the global financial crisis; drugs wars; and other contemporary crises. A Gendered Approach to the Syrian Refugee Crisis Edited by Jane Freedman, Zeynep Kivilcim and Nurcan Ozgur Baklacıog˘lu South-South Migration Emerging Patterns, Opportunities, and Risks Edited by Patricia Short, Moazzem Hossain and M. Adil Khan Living with Floods in a Mobile Southeast Asia A Political Ecology of Vulnerability, Migration, and Environmental Change Edited by Carl Middleton, Rebecca J. Elmhirst and Supang Chantavanich Undocumented Migrants in the United States Life Narratives and Self-Representations Ina Batzke Transnational Mobility and Global Health Traversing Borders and Boundaries Peter H. Koehn For more information about this series, please visit: www.routledge.com/RoutledgeStudies-in-Development-Mobilities-and-Migration/book-series/RSDM

Contents

List of boxes Foreword, by Ilona Kickbusch Foreword, by Susan Martin Foreword, by Unni Karunakara List of acronyms and abbreviations Introduction: the interconnected nature of contemporary population movements and global health

vi viii xi xiv xvii

1

1

Transnational travel as health insurance

38

2

Health challenges for refugees and conflict-induced migrants: transit conditions, camps, and settlements

58

Health challenges for other survival migrants on the move north: transit conditions and detention centers

82

3

4

Migrant health in Northern reception countries

104

5

Migration, health, and sustainable-development linkages: exploring southern contexts

148

6

Pathogens without borders: ERIDs as privilege leveler?

171

7

Climate change, health, and migration: the wild card in the deck

187

Where should we “move” from here? 21st-Century global-health education and service

204

Index

249

8

Boxes

I.1 I.2 1.1 1.2 2.1 2.2 2.3 2.4 3.1 4.1 4.2 4.3 4.4 4.5 4.6 4.7 5.1 5.2 5.3 5.4 6.1 6.2 6.3 6.4

Political origins of health inequity: excerpts from the LancetUniversity of Oslo Commission report Some non-state actors in global health and migration governance David’s physical therapy treatment in Cuba Kefei’s brain tumor treatment in Germany Venezuela’s Cruz Verde responds to protest injuries Civilian casualties in Mosul, Iraq, 2017 Direct health impairment through armed force: Kosovo Basic Health Care Units (BHU) operated by the Finnish Red Cross in Northern Greece Health care in Puerto Rico in the aftermath of Hurricane Maria Migration health policy in Greece Irregular migrants, deportation fears, and essential health services Illustrative TC-curriculum components: analytic domain Illustrative TC-curriculum components: emotional domain Illustrative TC-curriculum components: creative domain Illustrative TC-curriculum components: communicative domain Illustrative TC-curriculum components: functional domain Two migrants who fled and then returned to contribute to health care in the sending-country Kadijja Nantoga: a Ugandan face on the medical poverty trap NGO code of conduct for health systems strengthening Inverse care law Candidate Donald Trump on Mexican migration to the United States 2014 Scene from the Ebola isolation ward, Makeni, Sierra Leone Quarantine, West Point, Liberia, 2014 Donald Trump tweet after the airlift of two U.S. health workers infected with Ebola, 2014

7 10 42 45 59 62 64 68 85 105 107 117 120 122 124 127 148 150 151 152 173 174 177 180

Boxes vii 6.5 The quarantine of Kaci Hickox upon return from five weeks treating Ebola patients in Sierra Leone 7.1 Rural-urban migration in Bangladesh following Cyclone Aila in 2009 8.1 Tewolde Habtemicael’s circular-migration story 8.2 Upstream armed-conflict epidemiology

180 194 219 224

Foreword Ilona Kickbusch

People on the move – global health’s key 21st-Century challenge Many books with global health in their title deal exclusively with health challenges in developing countries. This book, though, goes to the heart of what global health is about: the transborder flows of health determinants, ideas, people, capital, goods, and services. Ulrich Beck, the great German sociologist, warned early on that the social sciences were still stuck in what he termed “methodological nationalism” rather than aim to understand what the interconnectedness and interdependence that comes with this historical wave of globalization means for people, societies, and economies. The core idea – as further developed by Andreas Wimmer and Nina Glick Schiller – is that we tend to conceptualize, analyze, and compare social phenomena around the boundaries of the nation state, with health being no exception. This makes us blind to phenomena and processes that are above or below the level of the nation state but that in due course lead to major shifts in how societies organize and how they interpret the world. In response, Saskia Sassen has tried to develop a sociology of globalization that analyzes global cities, diasporic communities, or transnational protest movements. Wimmer and Schiller – like this book – take the movement of people as an example of the momentous shift underway. Within a national context, the debate today still focuses around the exclusion or the integration of immigrants – whereas the defining characteristics of the great migration of the 21st Century have shifted radically. The new social phenomenon consists of transnational communities that live with multiple identities and whose key connectivity instrument is no longer the television program from home but the smartphone. In that way, they are more similar to the much traveled cosmopolitans than those who identify with place. This is the great 21st-Century disruption and – as Ivan Krastev states – the new revolutionary force of our age. It is not based on ideology but on movement. Its pure existence is changing sending and receiving societies – be it Europe, USA, or nations in the developing world. Some analysts say it will bring down the liberal world order and with it our coveted understanding of human rights. In health, the societal contradictions that emerge are evident. At present, the global health debate is very focused on the transborder movement of health

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threats and viruses. Clearly, this is important and requires action and cooperation at many levels of governance – local, national, regional, and global – to ensure global health security and the health of nations. Outbreaks can weaken and even destroy societies, and have enormous economic costs; for this reason, they gain high-level political attention. The health issues related to the movement of people have also gained high-level political concern – but it would be dangerous to establish a simplistic link in terms of health security. This is even more so as migrants themselves have been defined as threats, using language that claims that they “infest” the countries they are coming to. The very societies that are aiming to restrict movement are heavily dependent on it and could not run their health services without educated labor from abroad. The international migration of health workers is increasing, and future projections point to escalating mismatch between supply and economic demand. There has been a 60 percent rise in the number of migrant doctors and nurses working in OECD countries over the last decade. In the UK, 11 percent of all NHS staff and 26 percent of doctors are non-British; 30 percent of doctors practicing in Switzerland have foreign qualifications; this rises to 40 percent in hospitals; in Germany, 84,000 nurses are missing till 2020; until 2030, the gap is calculated to be over 200,000 nurses. WHO and its partners have begun to address the challenges of managing health workforce migration – one approach is to help countries implement the 2010 Code of Practice on the International Recruitment of Health Personnel. At the same time – as chapters in this book illustrate – the influx of patients from other cultures is challenging the health systems of the receiving countries. Increasingly, health systems need to become transnationally competent – not only if they aim for health tourism – and deal with the influx of both professionals and patients from other countries and cultures. A further factor that tends to be overlooked is the interface of transnational movement in the health sector and gender; the majority of the health workforce is female, and a majority of the workforce migration is women on the move. WHO, in a recent publication, has taken a transnational perspective on this phenomenon and drawn attention to a global paradox. Care workers – who are largely migrant women, often working in informal home settings – make a considerable contribution to public health in many countries but are themselves exposed to health risks, face barriers to accessing care, and enjoy few labor and social protections. The report shows the wide range of policy sectors – health, labor, employment, social protection, social services, education, law, immigration, cross-border movement, and citizenship – that require attention in both sending and receiving countries. It draws attention to the transnational existence of these women and the situation for their own households left behind, and explores their rights. This is another illustration of the dynamics explored in this book: the strong mobility and health interface and the glocal health and well-being consequences of unequal mobility, health conditions, and health rights. Global health has a strong focus on equity, but much of this is still within the confines of methodological nationalism. This book, I believe, is a step toward helping us overcome this conceptual boundary as it looks at the new dynamics of

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Ilona Kickbusch

inequality that emerge. Existing international agencies have not been set up for dealing with transnational mobility and its impact. The glaring gaps in the global governance of health that are becoming evident will need to be addressed. The Global Compact for Migration presently being negotiated is only a step along the way. Ilona Kickbusch Director, Global Health Centre, Graduate Institute of International and Development Studies Geneva

References Krastev, Ivan. Beyond the Great Disruption. New Statesman, February 2–8, 2018, 25–28. Sassen, Saskia. 2007. A Sociology of Globalization. New York: W.W. Norton. WHO. 2017. Women on the Move. Migration, Care Work and Health. Geneva: WHO. Wimmer, Andreas and Nina Glick Schiller, 2002. Methodological Nationalism and Beyond: Nation-State Building, Migration and the Social Sciences Global Networks, 2, 4: 301–334. ISSN 1470–2266.

Foreword Susan Martin

In the early 21st Century, nations appear to be at a turning point with regard to attitudes and policies related to international movements of persons as well as their relationship to other global issues, such as public health. Many negative trends fill the airwaves as I write this foreword. There are human crises that affect the almost 70 million refugees and asylum seekers in the world today and the unknown number of people displaced by natural disasters, the adverse effects of climate change, and other life-threatening situations. There are political crises – the growth in xenophobia, aggravated by nationalism and populist leaders throughout the world, including in countries such as the United States that have long seen themselves as nations of immigrants – which exacerbate the situation and create new dangers for people on the move. The zero tolerance of the Trump administration, which resulted in the separation of young children from their parents as they attempted to cross the U.S.-Mexico border is but one example of actions taken with little if any regard to their human consequences. But there are also positive developments that fly in the face of anti-immigration sentiments and actions. What had appeared throughout much of the 20th Century to be a firm belief that each sovereign country should manage migration across its borders unilaterally is evolving into an appreciation of the importance of international cooperation. Not that sovereignty does not play an extremely important role in setting policies. States retain the primary responsibility for migration. Nevertheless, there is growing recognition that unilateral policies fail in a context in which multiple states are involved as source, transit, and destination countries. The first notable achievements in generating collaborative approaches occurred at the regional level through informal consultation mechanisms. Source, transit, and destination countries in North America, South America, Africa, and East Asia have been meeting for decades to exchange best practices and work on mutual challenges. Since 2006, when the first UN High Level Dialogue on Migration and Development took place, states have recognized a need for global efforts along these lines. Ten years of progress through mostly informal consultations led to the 2016 New York Declaration on the large-scale movement of refugees and migrants in which the member states of the UN set out principles and effective practices that would allow governments to secure their borders when

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necessary while protecting the rights of refugees and other migrants. The declaration in turn launched a two-year process in which these same governments agreed to negotiate Global Compacts on Safe, Orderly and Regular Migration and on Refugees, to be adopted by the end of 2018. The rhetoric in both compacts is generally positive about migration, but the true test will be implementation of these agreements. In this context, there has also been a growing body of evidence as to the interconnections between international migration and other global issues. The nexus between migration and development has received the most attention in terms of both research and policymaking. The literature is vast, although new dimensions of the relationship continue to unfold. Importantly, migration indicators were in the Sustainable Development Goals adopted as part of Agenda 2030, thereby acknowledging that movements of people affect their own human development as well as the economic development of their home countries. The nexus between migration and the environment is another area receiving attention from both academics and policymakers. Research on the complex interconnections, especially between the effects of climate change and human mobility, alerted policymakers to three forms of movement resulting from environmental change – migration (that is, anticipatory movements of individual households), displacement (that is, mass movements of people because of sudden events), and relocation (that is, planned movements of communities generally involving some governmental support). To date, most attention is on displacement. The parties to the UN Framework Convention on Climate Change established a taskforce to make recommendations on displacement, and the global compact on migration makes recommendation for more effective prevention and responses to these movements. A coalition of UN agencies, with support from Georgetown University, have developed principles and identified effective practices for internal relocation related to environmental changes, and is providing training and technical assistance to governments. Comparatively less attention has been placed on anticipatory environmental migration by individuals and households, an important area requiring considerably greater attention. There have also been advancements in the understanding of the nexus between migration and health – which is the direct focus of this book. Just as migration can no longer be seen as an issue to be addressed by states working in isolation, health problems cannot be addressed solely within borders. Concerns about the impact of migrants on the health of natives as well as the cost of health care have been one source of alarm about migration in general, although, at least in the United States, these concerns have generally been overblown. Yet, with millions of travelers on the move each day, containing epidemics becomes more difficult and certainly requires international cooperation. At the same time, ensuring healthy lives for migrants and refugees requires transfer of data across borders as well as the sharing of expertise. Efforts to ensure that international migration does not aggravate health care access in developing countries, in a way that does not abridge the right of health professionals to move to where they may have greater opportunities, require substantial international cooperation as well.

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Moreover, policies adopted by states to manage migration can have a profound impact not only on the health of migrants, but on the communities in which they reside and from which they came. Peter Koehn has put together a masterful examination of these interconnections between migration and health among people moving for different reasons, through different channels, and in different economic and regional contexts. What sets this book apart and makes it so important are the ways in which it brings the disparate issues (including sustainable development and climate change) together into a holistic analysis of the nexus between migration and health. At its core, the book is concerned with the “global health and well-being consequences of unequal mobility,” in Koehn’s own words. Addressing unequal mobility is a challenge for all states, whether source, transit, or destination. This book holds great potential to educate researchers and policymakers alike on the issues and offers cogent recommendations for moving forward in finding solutions for clear and growing problems while seizing opportunities that migration can present in building healthier societies. Susan Martin Donald G. Herzberg Professor Emerita of International Migration Georgetown University

Foreword Unni Karunakara

The history of humankind is one of migration. Historically, migration was largely dictated by climatic factors and availability of food. Over thousands of years, humans migrated to new lands and continents in search of hospitable environments, in order to hunt, shepherd, farm, and trade. The nature and pace of migration changed considerably in the 16th century during the age of European exploration and colonialism. Large numbers left Europe for the Americas, Asia, and Africa, to plunder and fuel industrialization back-home. Migration was no longer only a consequence of need, but of greed. Brutal conquests, forced labour, and repatriated riches, all helped make European nation-states the paragons of modern democratic polities today. In the 20th century, industrialization gained steam and people started to move in search of jobs, not just from the former colonies, but also from Europe to the New World. Fuelled by visions of economic growth and wealth accumulation, many countries promoted labour migration. Growth in immigration gave rise to immigration policies that even when well-intentioned resulted in undesirable consequences. For example, the 1965 U.S. immigration reform that sought to achieve equality in the U.S. immigration system rendered historical migration flows illegal and progressively militarized the U.S.-Mexico border. The Border Patrol budget rose 16 times between 1980 and 2010 even though there was no rise in illegal immigration across the southern border. Fear of a hostile world has resulted in new political and social borders. Borders have been the cause of much suffering. Borders have become hostile environments where those fleeing persecution and poverty are dehumanised and victimised. As outsiders, migrants are excluded from rights and services afforded to citizens. Statelessness renders migrants invisible and exposes them to exploitation by guards, smugglers, and traffickers. Mary Kaldor suggests that displacement is perhaps the indicator that comes closest to a measure of human insecurity. Global migration has reached levels not seen since World War II. Around 70 million people are currently displaced from their homes, as a result of war, conflict, or persecution. Until the 1950s, refugees were mostly Europeans fleeing war, famine, and poverty. With decolonization in the 1960s, civil wars supported by global powers began to rage in Africa and beyond. Faced with violence and starvation, people began to move in large numbers. Migrants from poor countries

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rarely make it to rich countries. Most African migrants tend to settle in other African countries. More than half of all refugees are being hosted in Africa and the Middle East. In contrast, the relatively low numbers of people crossing the Mediterranean daily, at great peril, have generated fear and responses that belie European claims of solidarity and respect for international law. In a post-9/11 world, security concerns override any concern for human rights. The erosion of fundamental post-World War values and the global political progression of nationalism has  directly contributed to the ‘othering’ of refugees and asylum-seekers. As per Article 14.1. of the Universal Declaration of Human Rights ‘everyone has the right to seek and to enjoy in other countries asylum from persecution.’ However, by invoking security, Europe, the United States, and other developed nations are characterising migration and those seeking asylum as existentialist threats to their ‘way of life.’ Europe’s deals with Turkey and Libya that seek to externalize European borders have further exacerbated the vulnerabilities of asylumseekers. These policies have greatly dehumanized migrants and criminalized migration to the point where even rescue efforts are now viewed as illegal. We now live in a highly unequal world and our citizenship at birth further exacerbates inequality. In the era of globalisation, it is capital and not labour that is mobile. One-sided trade deals and global warming aid the flow of financial and human capital out of poor countries, creating deep imbalances in power. As a result, states with little control over economy and resources are unable to guarantee security and essential services to their citizens. Human insecurity fuels migration, further hastening the out-flow of resources. With the economy and information operating at a trans-national scale, it is not surprising then that migration levels have picked up pace in the last quarter-century and are unlikely to abate soon. Insecurity, in particular health insecurity, is an important push factor for migration. War is being waged with impunity as attacks against health structures and workers barely register outrage. Destruction of remaining essential services is a deliberate strategy aimed at emptying neighbourhoods and decimating resistance. Shockingly, four out of five permanent members of the UN Security Council have been part of coalitions that have bombed health facilities in the past years. Migrants remain vulnerable through the full-arc of their migratory experiences. Political and humanitarian efforts to meet migrant health needs have often fallen short, be it in refugee camps, transit centres, or in countries of asylum. Even when adequate political will and resources are mustered, considerable social, cultural, and logistical barriers remain. Meeting migrant health needs can be a challenge in well-resourced countries, let alone in countries where essential infrastructure is lacking. At times, migrant-health needs are cited as a reason for denying entry to those seeking asylum. By framing health as a security rather than a humanitarian concern, popular sentiments against immigration are reinforced. Following the 2014 Ebola outbreak in West Africa, travel restrictions that sought to limit travelers from affected countries were not all that successful. Passengers resorted to antipyretic drugs to suppress fever so as to escape detection at airports. In the

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United States as in West Africa, fear (and politics) played a big role in how infection control policies were implemented. In Transnational Mobility and Global Health, Peter Koehn expertly discusses the global challenges that arise from increasing migration. The precarity faced by migrants is a failure of politics and leadership. Koehn rightly zeroes in the need for a robust trans-national response to migrant-health needs. If the drivers of insecurity and migration are operating at a global scale, then any solution that hopes to succeed must also operate at that scale. The WHO Constitution (1946) envisages “the highest attainable standard of health as a fundamental right of every human being.” As non-citizens, migrants have little or no access to most national health services. If the international community is serious about meeting migrant-health needs, then the right to health should not be confined locally by borders, but should be realised globally. Any successful approach must include transnational solidarity, stable financing, and boost local capacities. There is much work to be done. Of the record $28 billion spent on international humanitarian assistance in 2016, a mere 0.2% was allocated to local agencies that are often the first to respond in times of crises. Policy proposals put forward by this book must be considered and developed further. Ultimately, we do need to address the disease rather than the symptoms. Migration must be seen as beneficial, and an opportunity if managed in a humane and sensitive manner. And a humane response must recognize the right of all migrants to seek care wherever they find themselves. Unni Karunakara Professor of Public Health,Yale University International President (2010–2013) Médecins Sans Frontières

Acronyms and abbreviations

A.I. AIDS AMPATH ANPA ASANTE BHU CBE CCTV CDC CHAI CIHC Convention COP21 CRED DRC EHB EMs EQUINET ERIDs G8 GAVI GDP GHC GHEC GHG GHMC GHRF GOARN GPHIN

artificial intelligence acquired immune deficiency syndrome Academic Model Providing Access to Healthcare Association of Nigerian Physicians in the Americas American Sub-Saharan Africa Network for Training and Education basic health-care units clinical breast examination China Central Television Centers for Disease Control and Prevention Clinton Health Access Initiative Center for International Humanitarian Cooperation 1951 Refugee Convention Conference of Parties to the United Nations Framework Convention on Climate Change Centre for Research on the Epidemiology of Disasters Democratic Republic of Congo essential health benefit approach explanatory models Regional Network for Equity in Health in East and Southern Africa emerging and reemerging infectious diseases France, United States, United Kingdom, Russia, Germany, Japan, Italy, and Canada Global Alliance for Vaccines and Immunizations gross domestic product Global Health Corps Global Health Education Consortium greenhouse gas Global Health and Migration Corps Global Health Resource Fund Global Outbreak Alert and Response Network Global Public Health Intelligence Network

xviii Acronyms and abbreviations GVF HIV HIVAN HMI ICRC ICT IDC IDHA IDPs IDRC IFRC IHRs IMF IOM IPCC IUPUI JCI LAMS LEADS LGBTI LMICs MDGs MEPI mHealth MPH MSF NCD NGO North NTDs NWFP OECD PDD PM PM2.5 PM10 ProMED or ProMED-mail PTSD RCAP

global viral forecasting human immunodeficiency virus Centre for HIV/AIDS Networking Harvard Medical International International Committee of the Red Cross information and communications technology International Detention Coalition International Diploma in Humanitarian Assistance internally displaced persons International Development Research Centre International Federation of Red Cross and Red Crescent Societies International Health Regulations International Monetary Fund International Organization for Migration Intergovernmental Panel on Climate Change Indiana University-Purdue University, Indianapolis Joint Commission International of the Joint Commission on the Accreditation of Health Care Organizations Latin American Medical School Linkage with Experts and Academics in the Diaspora Scheme (Nigeria) lesbian, gay, bisexual, transgender, and intersex persons low and middle-income countries Millennium Development Goals Medical Education Partnership Initiative mobile health through text messaging Masters of Public Health Médecins Sans Frontières (Doctors Without Borders) non-communicable disease non-governmental organization Global North neglected tropical diseases North-west Frontier Province (Pakistan) Organization for Economic Co-operation and Development pervasive developmental disorder particulate matter fine inhalable particles, with diameters that are generally 2.5 micrometers and smaller inhalable particles, with diameters that are generally 10 micrometers and smaller Program for Monitoring Emerging Diseases post-traumatic stress disorder Revised Community Assessment and Placement model

Contents

List of boxes Foreword, by Ilona Kickbusch Foreword, by Susan Martin Foreword, by Unni Karunakara List of acronyms and abbreviations Introduction: the interconnected nature of contemporary population movements and global health

vi viii xi xiv xvii

1

1

Transnational travel as health insurance

38

2

Health challenges for refugees and conflict-induced migrants: transit conditions, camps, and settlements

58

Health challenges for other survival migrants on the move north: transit conditions and detention centers

82

3

4

Migrant health in Northern reception countries

104

5

Migration, health, and sustainable-development linkages: exploring southern contexts

148

6

Pathogens without borders: ERIDs as privilege leveler?

171

7

Climate change, health, and migration: the wild card in the deck

187

Where should we “move” from here? 21st-Century global-health education and service

204

Index

249

8

Introduction The interconnected nature of contemporary population movements and global health

As discerned in film critic Manohla Dargis’ (2017) perceptive review of Ai Weiwei’s Human Flow, “ours is an age of ceaseless churn with no calm in sight.” Transnational Mobility and Global Health treats a range of timely and relentlessly churning topics – from tourism to terrorism, from war to resettlement, from the spread of infections to the impacts of climate change – that connect cascading mobility and health challenges. The issues raised in this book are only likely to become more intense as the 21st Century surge in transnational migration continues. In this challenging global milieu, meeting the health needs of mobile populations constitutes “a growing priority” (Villa-Torres, et al., 2017, p. 78). In life and health, “we are who we are because of where we have been and how that has shaped our understanding of where we are now” (Haines, 2017, p. xi). Perhaps, we also are who we are because we can empathize with those who have been elsewhere: A police officer cradled the body of a little boy who died after the boat he was in capsized on its way to Greece. Three people died and four were missing on Tuesday after a refugee boat carrying eight people capsized in a river that flows between Turkey and Greece. Overall Mediterranean arrivals to the European Union, including refugees making the longer and more perilous crossing from North Africa to Italy, stood at 172,301 in 2017. The number was down from 362,753 in 2016 and 1,015,078 in 2015, according to U.N. data. Rahman (2018) In an era distinguished by transnational migration, people, including particularly vulnerable people, increasingly are compelled to move. At the same time, some people with health concerns are finding it advantageous voluntarily to seek out care in foreign places. A vibrant health-tourism industry that taps into this motivation has become entrenched in sending and receiving places. Accelerated human mobility also ensures that microbes do not remain securely in place and isolated. Globalization and migration “are mixing people and microorganisms on an unprecedented scale” (Glasgow and Pirages, 2001, pp. 196, 203)

2

Introduction

at breakneck speed. Movers and non-migrating travelers spread communicable diseases to new human hosts, including to immobile persons inhabiting areas never exposed before (see, for instance, Tatem and Smith, 2010). In inescapable local places, transnational mobility “is generating epidemiological diversity and complexity” (Chen and Berlinguer, 2001, p. 36). Although morbidity and mortality associated with migration health “are the result (whether directly or indirectly) of local and international political decisions,” international relations, my field of study, has failed to keep pace with the manifold and complex linkages that bind politics with global health and transnational migration (Davies, 2010, pp. 2–3). For instance, the nature of armed conflict has fundamentally, and perhaps irreversibly, changed. Health personnel and facilities now are deliberately targeted. Civilian casualties are on the rise. Why should we care? First, because health is a human right. Everyone’s health matters. And, anyone can be health-secure today and health-vulnerable tomorrow. Further, it is costly not to act in a preventative manner. Negative fiscal and public-health consequences also can undermine political legitimacy and be politically disruptive. In a classic case, deliberate attempts by government authorities to conceal information about the initial SARS outbreak, coupled with institutional voids in preparedness, exacerbated the extent of transnational contagion, fanned public anger, and, ultimately, resulted in high-level disciplinary actions in China and Hong Kong (Olsson and Zhong, 2012; Koehn, 2007, p. 1053). We also are learning that health and well-being are imperatives if sustainable development is to be realized and the economic drivers of transnational migration are to be moderated. In addition, powerful appeals to people’s health concerns offer a promising way forward for the mobilization of actions aimed at mitigating drivers of climate change and attendant coastal displacement. At a fundamental level, migration “affects us all” (Dickenson, 2017, p. 7). The lived experiences of those who move impact those who stay behind and those on the receiving end. Transnational mobility brings the communicable presence and lifestyle-associated health practices and challenges of others to our doorsteps and catapults us into the hands of overseas caretakers and medical providers. Inescapably, we all inhabit the same health lifeboat (McCracken and Phillips, 2017, p. 16). From the shared lifeboat perspective, the lived health experiences of people on the move are at once illustrative, compelling, and personally relevant. Simply put, in the words of Nigel Crisp (2016, p. 8), “global health is the study, research, and practice concerned with issues that affect the health of us all wherever we live [at the moment].” The charge to the reader of Transnational Mobility and Global Health is to engage with empathy and foresight the pressing and arising issues of mobility, inequality, and global health (Penttinen and Kynsilehto, 2017, p. 157).

Mobility and health The useful concept of “mobility” covers various forms of human movement1 and encompasses the ability to migrate as well as the possibility of migration (Ionesco,

Introduction 3 Mokhnacheva, and Gemenne, 2017, p. 2). For students, scholars, policy makers, and other readers of this book, the risks and opportunities of mobility offer a fruitful focus for inquiry into contemporary population health. As Elizabeth Mavroudi and Caroline Nagel (2016, p. 7) note, “The concept of mobility is an attractive one that brings together multiple forms of human movement and circulation within a single analytical framework.”2 All types of mobility that involve health implications are of potential interest in this book’s treatment, although migration constitutes its principal focus. Migration requires “a stay of some substantial duration”; “rather than just visiting, the migrant is establishing some kind of a [open-ended or temporary] regular life in the place of destination” (Lindley, 2014, p. 8).3 Today, more than 230 million transnational migrants impact health and care provision around the world (Pottie and Gruner, 2016, p. 329). The migration option and the displacement condition have been part of people’s lived experiences throughout human history (Angier, 1998; Stoneking, 1998). Although most of us are attached to our familiar surroundings (Carens, 1996, p. 424), individuals, families, communities, social groups, and care providers actively pull up roots and venture to new locations. More than one in seven of Earth’s current population have moved their residence domestically or internationally (Swing, 2017, p. vi). Contemporary mobility often involves crossing national borders. When people move transnationally, the study of glocal health becomes particularly interesting and challenging.4 Migrants leave, travel, arrive, and return with individual health profiles, values, and beliefs (WHO, 2010, p. 9). Individual health conditions might be mitigated or compounded when adults and children are locationally mobile or care providers come to them. Each phase of the migration experience involves new and interconnected societal and individual impacts (Gushulak and MacPherson, 2006). For instance, migrant-receiving places encounter communicable and non-infectious “disease volumes and case-burdens [that] originate beyond the mandate and jurisdiction of national prevention and control efforts” (Gushulak and MacPherson, 2006). The analysis contributed in this book focuses at times singularly, and at times collectively, on the interface of mobility with both population health and individual health. Health and medical practices can be shared, exchanged, negotiated, discarded, and improved. In a world defined by people and products on the move, the diverse styles and temporal strands of mobility (Lyttleton, 2014, p. 27) inevitably connect and shape individual, family, community, and global health. The unique and fascinating journeys that define our lives encompass the ubiquitous effects of mobility on those who move and those who remain behind.5 In Arjun Appadurai’s perceptive words (1996, p. 4), “few persons in the world today do not have a friend, relative, or coworker who is not on the road to somewhere else or already coming back home, bearing stories and possibilities.”6 The “universality . . . of the mobility experience” (Skeldon, 1997, p. 204), and the life-long process of complex, positive and negative, health-related transnational interactions it engenders (Zhou, et al., 2017, pp. 645–646), clearly merit special attention and analysis in

4

Introduction

the 21st Century. In this endeavor, the transnational perspective facilitates “the consideration and study of the long-term consequences of movement between locations with different health determinants and health outcomes” (Gushulak and MacPherson, 2006). Transnational Mobility and Global Health: Traversing Borders and Boundaries spotlights the powerful and dynamic intersections of human movement and health. The selected interconnectors of agency and structure are multiple and multiplying, and their determinant, preventative, and healing implications often are complex and underexplored. This book is intended to enable readers to make sense of daunting and seemingly irresolvable contemporary manifestations of mobility-health interfaces around the globe. Conceptual analysis of lasting utility is privileged over preoccupation with transitory statistics. Through the lenses of careful scrutiny and enhanced awareness, each chapter further seeks to identify uplifting rather than downshifting responses. Readers will find the author not hesitant to advocate when promising alternatives to current policies, practices, and behavioral responses present themselves.7

Transnational mobility The conceptual analysis applied in this book primarily is concerned with transnational mobility. Although the borders of all countries are porous to a greater or lesser extent, nation-state boundaries continue to matter. States “simultaneously open and close themselves to mobile populations” and thereby “create multiple kinds of citizen-subjects who are positioned differently – some more marginally than others – within the body politic” (Mavroudi and Nagel, 2016, p. 152 [emphasis in original]; also pp. 156–161). Where one is positioned on the mobility track depends in large measure on ability to generate and sustain network capital – that is, helpful social relations with people “who are mostly not physically proximate.” (Elliot and Urry, 2010, p. 59). Like income levels, there are vast inequities in the distribution of network capital. While many struggle to move and to adjust after moving, “global elites” expand and employ network connections to “roam the planet,” exercising power and influence and consuming excessively along the way (Elliot and Urry, 2010, pp. 45, 64).8 However, frequent flyers are not immune to health challenges associated with extensive and intensive mobility. Jet setters are prone to acquire a range of health problems, including weight gain, high levels of low-density lipoprotein cholesterol, insomnia, and sleep deprivation, accidents and injuries, elevated stress, viral infections, and long-term chronic conditions (La Gorce, 2017). Although it is difficult to imagine that many, if anyone, can traverse the entire globe in a single lifetime, more than one million people cross nation-state borders daily and one million per week move between the Global South and the Global North (Garrett, 2001, pp. 185–186). Nevertheless, most border crossers stay within the South or the North. The bulk of international migration is South-South (Hossain, Khan, and Short, 2017, pp. 1–2).9 Roughly 37 percent of all transnational migration is from South to North and “only 3% from developed to developing countries” (WHO, 2010, pp. 8–9).

Introduction 5 Distinguishing major types of population movements allows us to analyze the multiple and diverse interfaces of mobility and health. Over a billion tourists cross one or more national borders annually (Mavroudi and Nagel, 2016, p. 8). In fiscal year 2011/2012, more than 65 million non-migrants entered the United States alone as temporary visitors for pleasure and/or business, temporary workers and families, students and exchange specialists, or diplomats (Satyen, et al., 2016, p. 489; also see Haines, 2017, pp. 64–66)10 at the same time that “60 million US citizens traveled overseas” (Mavroudi and Nagel, 2016, p. 8). Nearly “100 million people pass through British ports-of-entry each year” (Mavroudi and Nagel, 2016, p. 8). By 2012, some 4 million students traversed national borders (Chou, Kamola, and Pietsch, 2016, p. 5). Canada, a country that successfully encourages international students to become citizens, hosted more than 350,000 students from other countries (roughly 1 percent of its population) in the 2015/2016 school year (Smith, 2017). Transnational mobility also encompasses a substantial number of longerduration moves, or migrations.11 Roughly 3.3 percent of the world’s population are cross-border migrants (Connor, 2016). Most transnational migration follows South-South routes (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 8–9), although migrants are unevenly distributed on a nation-state basis (see Mavroudi and Nagel, 2016, pp. 9–11). Countries in Sub-Saharan Africa account for “eight of the ten fastest growing international migrant populations” (Connor, 2018).12 In absolute numbers, the United States has received more international migrants (46.6 million) than any other country (Connor, 2016). In aggregate terms, the proportion of international migrants to the total population increased from less than 9% in 2000 to 11% in 2013 in the developed countries, but has remained stable in developing countries (estimated at 2%) as a result of significant natural population growth and higher return levels. (Renzaho, 2016, p. 124) Applying a transnational migration perspective enables fully informed approaches to public policy and global health that “take into consideration the often transnational contexts that international migrants navigate” (Zhou, et al., 2017, p. 645). In most cases, mobility (and immobility) is “more or less voluntary or forced” (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 18 [emphasis added]; also Koser and Martin, 2011, p. 4). While typically determined by interacting elements of multiple and even offsetting considerations and conditioned by capacity to relocate, migration can be predominantly reactive or proactive. Although all migrations are the outcome of contextual interactions between human agency and structural forces beyond the immediate control of ordinary people . . ., it is also apparent that some migrations . . . are motivated more obviously by the immediate threat of violence and conflict than by economic interests. (Mavroudi and Nagel, 2016, p. 119; also Koehn, 1991)13

6

Introduction

By the end of 2016, nearly 41 million people had been internally displaced by persecution or armed violence (Gladstone, 2017b)14 while an estimated 50 million undocumented and irregular migrants15 lived outside their country of origin (Connor, 2016; Pottie, Hui, and Schneider, 2016, p. 293).16 A record 22.5 million refugees17 and roughly 43 million “persons of concern” to UNHCR who had fled a conflict situation were scattered around the world, mostly in Southern countries.18 Lebanon hosted the highest per capita concentration of refugees in 2014, 178 per 1,000 citizens (Kamara and Renzaho, 2016, p. 81; Mavroudi and Nagel, 2016, p. 138), and Syria and Iraq contained the largest numbers of internally displaced persons (Sengupta, 2016a). Vulnerable migrants who cross borders in pursuit of safety and enhanced and secure quality of life, which is “inextricably linked” to health (Hadler, 2015, p. 314), merit “a special moral claim to our attention” (Lindley, 2014, p. 12). Mitigating the negative health impacts on, and of, the most vulnerable segment of the world’s transnationally mobile population is the principal outcome that this book aims to advance.

Global health In both a discrete and an aggregate sense, global health is a central concern in the pages that follow. As a subject of study, international health tends to emphasize interactions among and affecting nation states. In some cases, the term is reserved for health interventions by international organizations and Northern professionals in the Global South (MacLean and Brown, 2009, p. 6). In contrast to international health, global health is concerned with any communicable or non-communicable health issue that affects populations in multiple countries and/or is influenced by developments and approaches that transcend territorial boundaries and the remedial capacity of individual states (MacLean and Brown, 2009, pp. 6–8). Thus, global health involves a synthesis of determinants of population well-being with individual treatment and outcomes (Lencucha and Mohindra, 2014, p. 66). As a subject of study, its ambition is to “treat” health in a truly global context. In the search for social and political determinants, then, “unlike international health – global health can focus on domestic health disparities as well as cross-border issues” (Koplan, et al., 2009, pp. 1993–1994).19 In this undertaking, disparities in the prevalence and burden of disease among population groups (health disparities) should be distinguished from disparities in access to resources and services (health-care disparities) (Berry-James, 2012, p. 183), although the two often are intertwined. Connecting political conditions and global health Of particular interest here, then, are adverse and positive health impacts that are manifest transnationally along with the transnational determinants of population health – that is, “how health is influenced by and influences the wider social, political, physical, and economic environment” (Crisp, 2016, p. 10).20

Introduction 7 While “factors such as housing, income, and employment – indeed many of the issues that dominate political life – are key determinants of our health and well-being,” the profoundly political nature of health and health inequities remains underdeveloped in the academic literature (Bambra, Fox, and ScottSamuel, 2005, pp. 187–189). In an exceptional contribution, the 2014 LancetUniversity of Oslo Commission on Global Governance for Health articulates a clear and consistent vision of the global political determinants of health and engages in compelling analysis of the power asymmetries and global governance dysfunctions that underlie health inequities (Ottersen, et al., 2014; also Harman, 2012, pp. 6–7). Box I.1 provides key excerpts from this carefully reasoned and documented report.

Box I.1 Political origins of health inequity: excerpts from the Lancet-University of Oslo Commission report The attraction of the biomedical model in global health stems from curative opportunities [plausibly linked to increased domestic and international investment in health] that have arisen from the substantial technological advances in medical treatment made during the past century. . . . But health inequities persist, and are in many instances on the rise. The biomedical approach cures disease, but it alone cannot address the root causes of health inequity. . . . The deep causes of health inequity cannot be diagnosed and remedied with technical solutions, or by the health sector alone, because the causes of health inequity are tied to fairness in the distribution of power and resources rather than to biological variance. . . . [Therefore, w]e regard health as a political challenge, not merely as a technical outcome. . . . For the continued success of the global health system, its initiatives must not be thwarted by political decisions in other arenas. Rather, global governance processes outside the health arena must be made to work better for health. . . . The Commission calls for stronger crosssectoral global action for health.21 Source: Ottersen, et al. (2014, pp. 636, 633, 631)

In short, health plays a growing role in international politics (Kickbusch and Ivanova, 2013, p. 22) and political determinants feature in the analysis of health and migration linkages developed in this book. “Looking at health through the lens of political determinants,” Ilona Kickbusch (2015) challenges us, “means analysing how different power constellations, institutions, process, interests, and ideological positions affect health within different levels of governance” (also Ottersen, et al., 2014, pp. 630–631, 633). Continued growth in indicators of extreme economic inequality (Elliot and Urry, 2010, p. 68; Neath, 2017)

8

Introduction

constitutes a foundational component of contemporary political power. At the same time, health impacts feedback to influence social and individual determinants (McCracken and Phillips, 2017, p. 690). Thus, just as politics conditions public health and well-being across jurisdictional levels, health decisions and outcomes influence political legitimacy through fiscal, labor, and gross domestic product (GDP) consequences22 and also impact citizen outlooks on politics (Kickbusch, 2015; McCracken and Phillips, 2017, p. 69; Harman, 2012, p. 140; Davies, 2010, pp. 56, 141). In the chapters that follow, therefore, the scope of health and migration investigation is not regionally circumscribed. The geo-political contexts for analysis include the South, the North, South-North interfaces and interconnectedness (Johnson, et al., 2012, p. 2033). Attention is devoted to the glocal interdependence of worldwide, regional, national, subnational, and individual23 determinants, challenges (see Kickbusch, 1999, p. 451; McCracken and Phillips, 2017, pp. 62, 64–66), and consequences. The field of global health As a field of study and practice, global health emphasizes “transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care” (Koplan, et al., 2009, p. 1994). Global health encompasses “prevention, treatment, and care,” emphasizes transnational-health issues, and places priority on improved and equitable health for all people in the world (ibid., p. 1995; Johnson, et al., 2012, p. 2033). The field is further understood today to encompass “development, governance, and security” (Huang, 2009, p. 129). Fundamentally, the diverse “collection of problems” that constitute global health “all turn on the quest for equity” (Farmer, 2013, p. xiii; emphasis in original). Consistent with a social-determinants framework and approach, promoting health equity requires “reductions in inequalities in the resources people need to make choices concerning their health” (Labonte, 2013, p. 92; also pp. 98–99; see also Budrys, 2017, pp. 152–156). Interest in global health stems in large measure from “the increasing mobility of humans through advances in global travel and communication” (WaltonRoberts, 2015, p. 238). In an age when exclusion and screening no longer offer viable strategies, “we need new, multinational, inclusive approaches that recognize the reality of modern human mobility and disease epidemiology” (Schenker, 2014, p. 10). To the extent that they are participants on the global health stage, both temporary visitors and longer-term (internal and transnational) migrants provide the mobile subjects for this book. Chronic and communicable concerns Chronic health concerns generally are non-communicable. It is useful to distinguish the diversity of non-communicable diseases (NCDs) as (1) life-threatening –

Introduction 9 “including cardiovascular and cerebrovascular diseases and associated major modifiable risk factors such as hypertension, smoking, obesity, and diabetes; cancer, diseases of the thyroid, Crohn’s disease and mental health disorders” and (2) non-life-threatening – “including chronic respiratory diseases such as asthma, back pain, allergies, ulcers, and diseases of the joints such as arthritis, and nutrition deficiencies such as vitamin deficiencies” (Renzaho, 2016, p. 129). Injuries and deaths from vehicle and workplace accidents and other causes (including suicides and homicides) span the two categories (see Table 3.2 in Crisp, 2016, p. 36; McCracken and Phillips, 2017, pp. 240–242; Jamison, et al., 2013, p. 1900). The distinction between communicable and infectious diseases also needs to be clarified. Communicable diseases “are passed from one human to another (via human to human contact, insects, animals or the environment)” (Davies, 2010, p. 134). While all communicable diseases are infectious, most, but not all, infectious diseases are communicable. Insect vectors and animal hosts can spread diseases that are “both communicable and infectious” (ibid., p. 134). Arising chronic-health issues along with pressing communicable-health concerns are particularly challenging in the Global South at the same time that poor countries experience the exodus of critically needed health-care providers (the “fatal flow of expertise”). Many countries in the South currently face “a heavy triple burden of infections, NCDs, and injuries, with tremendous health and financial consequences for households and societies” (Jamison, et al., 2013, p. 1899). Southern countries situated in tropical and subtropical zones suffer a particularly heavy burden of infectious disease. As John Connell (2010, pp. 13–14) notes, “geography affects disease prevalence”; specifically, “it is more difficult to control diseases where transmission takes place year round and affects a large part of the population.” Southern countries are at various stages of the epidemiological transition, where lifestyle diseases outstrip infections and place increasing demands on the limited available health workforce (Connell, 2010, pp. 14–15; McCracken and Phillips, 2017, pp. 204–205, 210–211, 222–224). Fully 85 percent of all mortality from non-communicable diseases occurs in low-income and middle-income countries (WHO data cited in Kamara and Renzaho, 2016, p. 89). The multidimensional convergence of infectious diseases and NCDs is induced and exacerbated by poverty, constrains economic development, strains inadequate health-workforce capacity in the South (Sheikh and Afzal, 2012, pp. 315–316), and can generate or reinforce health-induced domestic or cross-border migration. Negative health consequences too often are “only worsened as the behavioral risk factors for NCDs (alcohol, diet, physical activity, and tobacco) are inextricable from many of the aspirations and lifestyle shifts that accompany development” (Herrick, 2016, p. 675; also pp. 676, 678), migration, and the impact of upstream corporate interventions (Scott, Carriedo, and Knai, 2016; MacKenzie and Hawkins, 2016). The underestimated and often neglected burden of mental illness further complicates global-health care (see Crisp, 2016, pp. 65–67; McCracken and Phillips, 2017, p. 227). The combined challenges of noncommunicable and infectious diseases, injuries, and disturbance to mental health constitute a recurring concern in Transnational Mobility and Global Health.

10

Introduction

Fragmented governance Governance can be understood as influence over policy and action.24 Throughout the world, multiple and at times conflicting political considerations and policy decisions affect health and migration outcomes. In the current diffuse international context, a multitude of diverse and uncoordinated institutions participate in multilevel health and mobility governance (Sheikh, et al., 2016; Herrick, 2016, p. 674; Harman, 2012, pp. 6, 141; MacLean and Brown, 2009, pp. 9–10, 14). Governments at the national and subnational levels25 play important, but often not decisive, governance roles in complex-humanitarian crises. Multinational organizations, led by the World Health Organization (WHO) and the United Nations High Commission for Refugees (UNHCR), are active at the international and regional level.26 Non-state actors (see Box I.2) are other key players at different times and in different places (see, for instance, Kirton and Cooper, 2009, p. 314; MacLean and Brown, 2009, pp. 11–13; Moran, 2009; McCracken and Phillips, 2017, p. 26; Barmania and Lister, 2013; Kickbusch, et al., 2013, pp. 2–3; Davies, 2010, pp. 49–50, 55–58).

Box I.2 Some non-state actors in global health and migration governance • • • • • • • • • • • •

corporate firms (such as pharmaceutical and tobacco companies)27 Doctors Without Borders, Red Cross and Red Crescent foundations28 and philanthropic organizations29 the Global Fund to Fight AIDS, Tuberculosis, and Malaria,30 the Global Alliance for Vaccines and Immunizations (GAVI) International Rescue Committee31 indigenous humanitarian organizations (Land, 2017 , pp. 128–129) private local hospitals, faith-based entities, citizen-initiated sanctuary cities, political movements (Ottersen, et al., 2014 , p. 635) the traditional and social media academic and professional networks and expert bodies the Internet mixed-actor partnerships

Global health governance specifically refers to “trans-border agreements or initiatives between states and/or non-state actors to [sic] the control of public health and infectious disease and the protection of people from health risks or threats” (Harman, 2012, p. 2; also p. 144; also Davies, 2010, pp. 59–61). WHO is “the directing and coordinating authority for health within the United Nations system” with multiple core-leadership functions that span research and knowledgegeneration, policy articulation, norm-setting, capacity building, technical support,

Introduction 11 and monitoring global health conditions and trends (Renganathan, 2013, p. 174; also see Kamradt-Scott, 2015, pp. 16, 169). With an annual budget of about $2 billion (70 percent of which is dependent upon voluntary and earmarked contributions that are primarily allocated to vertical programs of special interest to donors), WHO’s underfunded and overstretched operating responsibilities include coordinating a vast surveillance network of national laboratories, fighting non-communicable and communicable diseases, health promotion, and dealing with pandemic outbreaks (Davies, 2010, pp. 34, 54; Huang, 2016). Its cumbersome administrative structure consists of health ministers from 194 member states, 150 local offices, and six highly autonomous regional offices operated by officials with local political ties (Huang, 2016). Members overwhelmingly elected Dr. Tedros Adhanom Ghebreyesus of Ethiopia to serve as WHO’s Director General in 2017 (McNeil, 2017a, p. D3).32 An experienced foreign minister and past Chair of the African Union’s Executive Council Dr. Tedros “knows and understands the world of power” (Kickbusch, 2017). In the “increasingly multi-polar and politicized world of health” (ibid., 2017), WHO and its new Director General face multiple and complex challenges. From Ilona Kickbusch’s astute perspective, Dr. Tedros can exert a powerful impact on global health governance by applying his political capital and competence in accordance with a cross-sectoral “health in all policies approach” that specifically addresses sustainable development, climate change, and the “health rights of people migrating.” The landscape of global health governance Wolfgang Hein’s comprehensive depiction visually displays the crowded landscape of contemporary global health governance (see Hein, 2013, Figure 5.3, p. 64). Governance and health diplomacy typically are fragmented among the multiple and diverse actors involved both within and across the spheres of global health and migration (Barmania and Lister, 2013, pp. 260, 265; Cooper, 2013, p. 246). Nigel Crisp (2016, p. 134) reports that, to the detriment of good governance, more than 150 United Nations-family bodies are involved in health to some extent (also see Blouin, Pearcey, and Percival, 2013, p. 209).33 The stronger message of the Commission on Global Governance for Health maintains that “the present system of global governance fails to adequately protect public health. This failure strikes unevenly and is especially disastrous for the world’s most vulnerable, marginalized, and poorest populations” (Ottersen, et al., 2014, p. 631). Humanity urgently “needs a new global health compact, which tackles issues of financing and of governance far beyond the WHO” (Kickbusch, 2017). Variable and contextual consequences In the absence of globally integrated institutions and approaches (Lunt, Horsfall, and Hanefeld, 2015, p. 12), outcomes and impacts will be contextual rather than uniform and mobility-health interfaces will vary depending on the relative influence exercised by different proximate and distant governance agents in spatially

12

Introduction

differentiated circumstances. Thus, place and health interact in a dynamic and uncertain manner with emergent and unintended consequences (Herrick, 2016, pp. 677–678, 683). In a helpful insight regarding global governance, Kearsley Stewart (2017, p.  115) reminds us that the ultimate relevance of public-health-care recommendations and regulations generated “beyond the borders of nation states” is dependent on acceptance “at the local level where they become lived experiences.” Since global governance is no longer exclusively determined by inter-state negotiations, “transnational relations are not squeezed into diplomatic rules and traditional means of exerting pressure on other states by the application of power politics or through the complicated mechanisms of international organizations” (Hein, 2013, p. 64). In global health and migration matters, like other forms of governance, therefore, one must not overlook “the ability of people and places to resist, evade, and exceed governance efforts” (Herrick, 2016, p. 683). Free and secure, WhatsApp “has become the lingua franca among people who, whether by choice or force, have left their homes for the unknown” (Manjoo, 2016, p. B1). Nevertheless, “when health is compromised by transnational forces,” the response must include global actors, norms, and improved responses (Ottersen, et al., 2014, p. 637; also pp. 630, 632). Amid the diversity, complexity, and contingency of a multilayered governance process, the quest for equity across a variety of challenges provides the “driving force of the global health agenda” (Kickbusch and Rosskam, 2012, p. 4; also pp. 2–3) and the basis for agreement that health is a human right for all people (WHO, 2010, p. 47). Kabir Sheikh and colleagues (2016) maintain that global health practices must “actively span and disrupt boundaries . . . which are rooted in imbalances of power and resources.” In these efforts, transnational learning networks, local communities of practice, and “learning organisations with a global outlook in low and middle-income countries can be effective boundary-spanners, and need to be supported” (Sheikh, et al., 2016). Fragmented international governance and conflicting national objectives constrain the development and implementation of unified and effective migrationhealth policies. In particular, policy approaches have not kept pace with growing challenges associated with the volume, speed, diversity, and disparity of modern migration flows and do not sufficiently address the existing health inequities, gaps in social protection, and determining factors of migrant health including barriers to access health services, goods, and facilities. (WHO, 2010, p. 43; also p. 44; also MacLean and Brown, 2009, p. 14) This situation also exacerbates health-security concerns. Health security concerns Health and security are related in multiple ways, from bioterrorism and pandemics to disruptions of public services and law and order and weakened military

Introduction 13 capacity (McCracken and Phillips, 2017, pp. 325, 362; Kamradt-Scott, 2015, p. 3; Davies, 2010, p. 3). From a societal perspective, “global health security means reducing collective vulnerability to global public-health threats, both immediate and gradual” (Heymann and Chand, 2013, p. 126; also Kamradt-Scott, 2015, p. 3). Under the prevailing governance arrangement, global and national actors share responsibility for determining the appropriate response to emerging health threats (Davies, 2010, p. 153). Threats to health security often catalyze cross-border or domestic migration. The health risks associated with food insecurity, including hunger and malnutrition (e.g., Kohut and Herrera, 2017), can stimulate individual, family, and mass migration (McCracken and Phillips, 2017, pp. 333–335). In an unusual case that links health, migration, and security, “severe hearing loss, possibly caused by a covert sonic device” led sickened U.S. foreign-service officers to leave Cuba in August 2017 (Cochrane, 2017; also Harris, 2018), a move which, in the wake of staff reductions, effectively halted authorized immigration from Cuba to the United States (Londono, 2017). Chapter 6 is devoted to past and future pandemics of emerging and reemerging infectious diseases (ERIDs). Transnational mobility is at the core of healthsecurity concerns related to ERIDs. ERID challenges include surveillance capacity, outbreak-alert systems, rapid-response mechanisms (see McCracken and Phillips, 2017, pp. 362–363), and collaboration among trade and health specialists (Hancock, 2013, p. 162). Contrary to widespread beliefs and the WHO’s inconsistent and conflicted employment of “health-as-security” discourse (Kamradt-Scott, 2015, pp. 165, 182–187), “the risk for importation of exotic and rare infectious agents into Europe, such as Ebola, Marburg, and Lassa viruses or Middle East respiratory syndrome (MERS), is extremely low.” Moreover, “experience has shown that, when importation occurs, it involves regular travelers, tourists or healthcare workers rather than refugees or migrants.”34 Unquestionably, most countries in the North as well as the South “have weak surge capacity in addressing a pandemic outbreak” (Huang, 2009, p. 132). The potential domestic and global economic damage wrought by a pandemic is enormous (Huang, 2009, p. 139). On the other hand, the tendency of national and international policy makers to emphasize “communicable diseases rather than lifestyle risk factors and preventive care” (WHO, 2010, p. 43) is cause for concern in terms of a comprehensive global approach to protection from threats to human health. Sara Davies (2010, p. 18) maintains that emphasis on securitization is: well suited for addressing acute crises, but less well suited for chronic health crises.  .  . . Identifying bio-weapons along with pandemic influenza, for example, as health security threats will facilitate policies to prevent these particular health crises, but it may not alleviate the underlying causes of infectious disease – which include poverty and poor health care in developing countries – and may even draw resources away from these areas. . . . Nor are all cases of poor health that affect large numbers of the world population the result of communicable disease.

14

Introduction

Framework for analysis Permeable boundaries provide a useful conceptual link in the analysis of transnational mobility and global health. In her review of Maria Thereza Alves’ Seeds of Change projects,35 Jean Fisher (2016) draws attention to “boundaries – geographical, social or cultural” that “create binary oppositions: inside/outside, native/foreigner, citizen/non-citizen, cultural authenticity/inauthenticity, assimilation/isolation, and so forth.” In Joel Migdal’s enlightening conceptualization, “boundaries signify the point at which something becomes something else, at which the way things are done changes, at which ‘we’ end and ‘they’ begin, at which certain rules for behavior no longer obtain and others take hold” (Migdal, 2004, p. 5). By penetrating permeable spatial, virtual, socio-cultural, and cognitive boundaries, human mobilities upend dichotomies and oppositions. As action sites where “different ways of doing things meet” (ibid., pp. 6, 23), boundary interfaces often involve uncertainty, tension, and creative opportunity. Mobility exchanges “blur the distinctions between inside and outside,” although health and belonging remain “a constant process of negotiation” (Fisher, 2016; also Mavroudi and Nagel, 2016, pp. 178, 182, 198, 218). Solidarity across boundaries emerges as a potent potential force for change (Upshur, Benatar, and Pinto, 2013, pp. 30–32). At the same time, mobility-opportunity divides persist across social, economic, and political lines (Mau and Mewes, 2009, pp. 169–180). Contestations over access to the application of political power drive and shape the distribution of health and mobility opportunities and determine wellness and illness outcomes. The unequal transboundary interplays of education, occupation, competencies, and resources with migration and health provide the novel thematic frame for analysis in Transnational Mobility and Global Health: Traversing Borders and Boundaries. Rather than belabor disciplinary theoretical positions and debates, this book emphasizes analysis, practice, and insights that shed light on “now what” questions (Janes, 2003, p. 90). Its health-centered and mobility-driven conceptual framework is grounded in human agency, enablers, and prospects that “the ‘native’ and the ‘alien’ may come to balance the relations of hospitality and hostility and recognize a political solidarity in shared experiences, interest, and goals” (Fisher, 2016). Progress toward shared analytic understanding of common interests in universal well-being is important both ethically and practically because “addressing migrant health is a necessary precondition to full realization of the benefits of migration for those who migrate and for both countries of origin and destination” (WHO, 2010, p. 55). Contextual rather than essentialist social determinants and policy facilitators and constraints fill out the dynamic platform for analysis. People are displaced or elect to move based on a specific combination “and quite often also a culmination” of factors (Lindley and Hammond, 2014, p. 66). Political, economic, social, environmental, aspirational, and health-related considerations feature in contextual unmaskings. In places of origin and destination, as well as along the way, transnational mobility often is socially and politically transformative, “far from being a marginal phenomenon” (Lindley and Hammond, 2014, p. 68) for those on the move as well as those spatially stable.

Introduction 15 The capability to migrate will not result in spatial movement “if people do not desire to do so” (Flahaux and De Haas, 2016, p. 4). The desire to migrate depends on “general life aspirations,” including health-care aspirations, and changing “perceptions of the extent to which these aspirations can be fulfilled ‘here’ and ‘there’” (Flahaux and De Haas, 2016, p. 4). Subjective perceptions that “there” offers better health-care opportunities differentially develop among persons with improved access to information and increased exposure to traditional and social media and advertising that emanates from the North (Flahaux and De Haas, 2016, p. 4). The framework for analysis applied in Transnational Mobility and Global Health recognizes that critical activated dimensions of mobility privilege and restrict health-seeking migration. In the interest of health promotion as well as other opportunities, “individuals, families, and communities use mobility in sometimes pre-emptive, often reactive, and other times more strategic fashion” (Lindley, 2014, p. 16; also Lindley and Hammond, 2014, p. 67). Philip Marfleet and Adam Hanieh (2014, p. 26) report that “for some migrants, changes that prompt their journeys are unwelcome or even threatening, and migration itself is undesired and dangerous; for others, change is positive, presenting new opportunities, including those offered by migration.” On stage, the migration dramas by NigerianAmerican playwright Mfoniso Udofia similarly “offer a moving and powerful corrective to the notion that what immigrants leave behind is always awful, and that what they find is always worth the trip” (Green, 2017, p. C1). Further, the international regime, political persecution and oppression, armed conflict, and border controls shape mobility options. The ability of individuals to relocate long distances and secure desired health benefits is contingent upon key upstream,36 midstream, and downstream behavioral and structural factors that are contextually present or absent (see McCracken and Phillips, 2017, pp. 70–72). Foremost among these conditioning enablers are class, transnational competence (see Koehn and Rosenau, 2010), and access opportunities (place, time, transport, and nation-state-reception policies).37 In all cases, moving “from latent to manifest mobilities is highly related to inequality structures” (Ohnmacht, Maksim, and Bergman, 2009, p. 13). Moreover, the health benefits and costs of transnational mobility are inequitably distributed at regional, national, and individual levels. Addressing the daunting and interconnected “now what” challenges of mobility and health, then, requires multifaceted attention to primary-, secondary-, and tertiary-prevention prospects (McCracken and Phillips, 2017, pp. 71–72).

Health and mobility issues of special global concern Individual-, family-, and community-health prospects associated with unequal population movements of different types (proactive and reactive, short-term and long-term, distant and proximate, recognized and undocumented) are of special interest in this book. Two recurring dynamics shaped the choice of the thematic cases selected for attention in the chapters that follow: (1) the presence of a robust and important transnational mobility-health interface that unmasks and

16

Introduction

illuminates (2) the glocal health and well-being consequences of unequal mobility. Practical approaches to addressing the determinants of unequal mobility and health conditions are incorporated throughout the work. Migrant health, human rights, and the provision of humanitarian medicine emerge as core global health concerns that are treated in-depth in Chapters 2 through 4. Mobility impacts on the dynamic interaction of health, resilience, and sustainable development, along with the paradigm shift “from pathogenic to salutogenic thinking” (Astier, 2008, p. S10), receive attention in Chapter 5. The “fatal flow of expertise” also is unpacked in Chapter 5. South-South and South-North population movements capture the bulk of attention in light of their critical global implications for individual and population health. However, North-South mobility in search of health benefits (treated in Chapter 1) has a powerful conditioning impact on local opportunities and, therefore, must not be overlooked. The “two migration processes of [health-care] workers and patients cumulatively affect the ability of health systems to equitably and adequately deliver health care” (Walton-Roberts, 2015, p. 238). Patient mobility aka health tourism The first chapter of Transnational Mobility and Global Health is devoted to travel health and to health tourism, a practice of increasing popularity, particularly among wealthy Northerners and Southerners.38 Transnational care constitutes a growing manifestation of unequal mobility that merits attention in a book that aims to provide a comprehensive treatment of health and population movement. Patient transnational travel in search of health benefits constitutes the paramount focus of attention in Chapter 1. Although traveling to receive health care has a long history (Lunt, Horsfall, and Hanefeld, 2015, pp. 3–5), current medical tourism is quantitatively greater in terms of patient numbers and competing treatment sites at the same time that it is qualitatively challenged by unintegrated demand and supply developments (Lunt, Horsfall, and Hanefeld, 2015, p.  6). A conservative estimate holds that some five million international patients per year engaged in medical tourism by 2010, generating an estimated market value of $2.5 billion in treatment expenditures (Horsfall and Lunt, 2015, pp. 27–33). The increasingly popular global phenomenon of long-distance travel is associated with particular health challenges that require pre-departure, in-transit, and posttravel attention (Leder, et al., 2013). The market entry of low-income and middle-income countries has realigned the supply side. Patient-care enhancements, affordability,39 and the emergence of transplant tourism are strategies designed to increase the appeal of Southern treatments. Simultaneously, “the diffusion of surgical techniques and patient safety knowledge, combined with the circulations of clinicians who have trained within, or have experienced, overseas systems [has] facilitated the internationalization of techniques previously confined to Western nations” (Lunt, Horsfall, and Hanefeld, 2015, p. 7). Global governance of medical tourism remains to be seriously addressed, however.

Introduction 17 The ethical problems of medical tourism merit considered treatment from the perspective of unequal mobilities. Of particular interest in Chapter 1 is the macro level of ethical concern: “commercialization of health care, access to health care, equity, state obligations and responsibilities” (Pennings, 2015, p. 341), and so forth. Health challenges for conflict-induced migrants The health perils associated with population mobility and forced immobility (Lindley and Hammond, 2014, p. 67) considered in Chapter 2 stand in stark contrast to those related to medical tourism. Exposed and unprotected civilians bear the brunt of most casualties resulting from contemporary armed conflicts. Increasingly, parties to conflict are targeting health facilities rather than “respecting them as sanctuaries” (Antonio Guterres, cited in Sengupta, 2017) and are attacking medical and responding personnel (Sengupta, 2017; Toole, 2006, p. 199). In November 2016, for instance, aerial bombing damaged eight hospitals and killed and injured health workers in Northern Syria as part of what humanitarian agencies identified as a deliberate attack on health-care facilities and the World Health Organization condemned as “a major violation of international law and a tragic disregard of our common humanity” (Barnard and Saad, 2016; also Rubin and Saad, 2016; Gordon, 2017; Sengupta, 2017). That same month, scores of wounded civilians fleeing Mosul, Iraq, suffered “horrific injuries”; they had to travel for hours to reach medical care, first, at field clinics and, later, at overwhelmed hospitals in Erbil (Arango, 2016, p. A8).40 A few months earlier, Médecins Sans Frontières evacuated its pediatricians, obstetricians, surgeons, and emergency-room staff from Northern Yemen in the wake of the fourth bombardment of a supported health facility by the Saudi-led coalition that killed 19 people at Abs Hospital (Almosawa and Nordland, 2016). In March 2017, Islamic State gunmen attacked the main military hospital in Kabul, Afghanistan, killing at least 30 hospital staff, patients, and visitors and wounding more than 50 others (Mashal and Abed, 2017).41 Unsafe conditions in conflict areas “contribute significantly to an increase in the brain drain of health workers to more secure and rich countries” (Sheikh and Afzal, 2012, p. 315). For those who survive, the “first killer is flight.” Forced displacement “increases the risks of adverse health outcomes, particularly for vulnerable groups such as children, women, the elderly, and those with pre-existing illnesses” (McMichael, Barnett, and McMichael, 2012, p. 648).42 Tim Arango (2016, p. A1) reports, By the time little Amira, just a year old, reached the field clinic near the front line in Mosul, she was already dead. . . . It was barely noon on Wednesday, and eight bodies had already arrived at the clinic, an abandoned house where medics provide a minimum of treatment, just enough to keep the lucky ones alive for the hourlong drive to a trauma center. Some 40,000 persons perished in migrant border corridors (particularly the Mediterranean Sea) and border zones between 2000 and 2014 (Pottie, Hui, and

18

Introduction

Schneider, 2016, pp. 292–293).43 Long after armed conflicts have ended, land mines, the explosive remnants of war, continue to cause casualties among civilians, particularly children, on the move (Gladstone, 2016; Onishi, 2017; Gladstone, 2017a; Cahill, 2017, pp. 29–30). Specific dimensions of the migration process further shape health outcomes, often with long-term ramifications (WHO, 2010, p. 37). Maintaining health remains a particularly challenging proposition for persons who escape activeconflict theaters and join the internally displaced44 or flee across national borders. Following persistent discrimination in access to medical care, arbitrary killings, and village destruction in Myanmar, for instance, members of the persecuted Rohingya ethnic group encounter life-threatening health conditions in Rakhine State, in camps for internally displaced persons, and in refugee camps in Bangladesh (Ives, 2016). Initially, in camps and crowded settlements, “the most significant burden of disease is mainly infectious and communicable disease” (Kamara and Renzaho, 2016, p. 81; also McMichael, Barnett, and McMichael, 2012, p. 648). In addition, pre-and post-displacement mental-health problems and chronic illnesses such as diabetes, hypertension, and cardiovascular diseases, although frequently overlooked and neglected, present serious health burdens among refugee populations (Kamara and Renzaho, 2016, pp. 81, 89–90; McMichael, Barnett, and McMichael, 2012, p. 649). As a consequence of chronic and acute malnutrition, “stunting and underweight are also very prevalent among refugees” (Kamara and Renzaho, 2016, p. 91). Migration in the face of complex-humanitarian emergencies: mortality and morbidity hazards Whereas Chapter 2 focuses on refugees, asylum seekers, and “people of concern” to UNHCR, Chapter 3 is devoted to migration in the face of complexhumanitarian emergencies where people’s safety, subsistence, and/or health can no longer be provided by governments, communities, families, and individual efforts. Chapter 3 specifically explores mortality and morbidity hazards associated with undocumented and irregular migration (e.g., Fernandez, 2017); natural ecological catastrophes; industrial accidents; land grabbing (see Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 38–49, 54–57); and human smuggling and trafficking. Health-detracting conditions in initial sites of refuge such as camps and detention centers (Pottie, Hui, and Schneider, 2016, p. 298; Cyril and Renzaho, 2016, pp. 216–228), particularly in situations of protracted displacement, are exposed and assessed in this chapter. The physical movement of displaced people from one place to another constitutes a particularly potent transmission mechanism. In certain internal and transnational migration situations, especially where screening is problematic, host populations incur increased risk of contracting infectious diseases (McMichael, Barnett, and McMichael, 2012, p. 650). In the face of disasters of increasing frequency, magnitude, and scope, international protection for health as a human right and the practice of humanitarian

Boxes

I.1 I.2 1.1 1.2 2.1 2.2 2.3 2.4 3.1 4.1 4.2 4.3 4.4 4.5 4.6 4.7 5.1 5.2 5.3 5.4 6.1 6.2 6.3 6.4

Political origins of health inequity: excerpts from the LancetUniversity of Oslo Commission report Some non-state actors in global health and migration governance David’s physical therapy treatment in Cuba Kefei’s brain tumor treatment in Germany Venezuela’s Cruz Verde responds to protest injuries Civilian casualties in Mosul, Iraq, 2017 Direct health impairment through armed force: Kosovo Basic Health Care Units (BHU) operated by the Finnish Red Cross in Northern Greece Health care in Puerto Rico in the aftermath of Hurricane Maria Migration health policy in Greece Irregular migrants, deportation fears, and essential health services Illustrative TC-curriculum components: analytic domain Illustrative TC-curriculum components: emotional domain Illustrative TC-curriculum components: creative domain Illustrative TC-curriculum components: communicative domain Illustrative TC-curriculum components: functional domain Two migrants who fled and then returned to contribute to health care in the sending-country Kadijja Nantoga: a Ugandan face on the medical poverty trap NGO code of conduct for health systems strengthening Inverse care law Candidate Donald Trump on Mexican migration to the United States 2014 Scene from the Ebola isolation ward, Makeni, Sierra Leone Quarantine, West Point, Liberia, 2014 Donald Trump tweet after the airlift of two U.S. health workers infected with Ebola, 2014

7 10 42 45 59 62 64 68 85 105 107 117 120 122 124 127 148 150 151 152 173 174 177 180

20

Introduction

Migration, health, and sustainable development The sustainable-development goals (SDGs) and targets adopted by U.N. member states in 2015 continue to emphasize the importance of a global health agenda, explicitly link health to social and political determinants (Crisp, 2016, pp. 141–142; McCracken and Phillips, 2017, pp. 192–193; also see WHO, Commission, 2008, pp. 1–3), and “integrate migration policies and the role of migrants, their communities and diasporas, into development strategies” (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 95). Chapter 5 explores why health is a paramount driver of sustainable development and how mobility affects the process. The discussion of health/development interdependencies involves enabling and constraining conditions; the impact of transnational trade and advertising on local health; the interface of mobility, sexual intimacies, health, and development (Lyttleton, 2014, pp. 6–9); the impact of medical tourism; community awareness; resource allocation; economic and social remittances;47 failed policy responses; NGO roles;48 and health care as a promising vehicle for policy transformation. The fatal flow of expertise, task shifting (Mackey and Liang, 2013), and deliberate policies aimed at the export of health-care professionals to wealthy countries characterized by chronic deficits (Frenk, et al., 2010, p. 1934) receive in-depth attention. By Crisp’s estimates (2016, p. 199), some 60 million persons, including 9.2 million physicians and 18.1 million nurses, comprise the world’s health-care workforce. The estimated current Southern shortfall of approximately 2.5 million doctors, nurses, and other health-care workers, primarily in Africa and Southeast Asia, is exacerbated by the emigration of health professionals. In 2010, nearly 130,000 physicians educated in economically challenged countries49 provided vital medical services in the United States (Nwadiuko, et al., 2016; Renzaho, 2016, pp. 144, 147). South-South and internal drains of professional expertise further exacerbate profound regional disparities, with negative consequences for sustainable development and domestic-health-care needs (Renzaho, 2016, pp. 148–158). Poverty and gross disparities in the distribution and density of health workers are closely associated with professional-migration pathways and motives (Connell, 2010, p. 13; Connell, 2014; Crisp, 2010, pp. 69–72). The negative population health consequences of the departure of health expertise are monumental. At the height of the Ebola outbreak, for instance, more than half of Liberia’s nationally trained physicians practiced medicine overseas and 51 doctors served the country’s five million citizens (Nwadiuko, et al., 2016). On the other hand, diaspora communities are engaged in a wide spectrum of time and monetary contributions to sending-country health systems, including circular and return migration (Nwadiuko, et al., 2016; Renzaho, 2016, pp. 159–161; Crisp, 2010, p. 67). The circular migration of health-care professionals carries potential for mutual source-country and receiving-country (as well as individualcare-receiver) benefits (Renzaho, 2016, pp. 138–139; Crisp, 2010, pp. 122–124). Chapter 5 suggests promising enhancements of diaspora involvement. At the

Introduction 21 same time, enabling receiving-country benefits from migrant health and development professionals requires consideration of issues of “brain waste”50 or deskilling (Mavroudi and Nagel, 2016, pp. 76–77) and reskilling. The challenges of ERIDs The critical biomedical, cultural, social, psychological, ethical, and governance challenges of emerging and reemerging infectious diseases are treated in Chapter 6. Most ERIDs have zoonotic origins and move from South to North, with the potential in a “globalized microbial world” to erupt simultaneously in distant places (Kirton and Cooper, 2009, p. 312; Onishi and Mouawad, 2014). Lessons from the 2014/2015 Ebola epidemic, including future applications of Médecins Sans Frontières’ ethics framework for medical research, addressing upstream environmental contributors (McCoy, 2014), improved protections for healthcare workers, and rapid personnel and resource mobilization (Fink and Belluck, 2015), are considered along with efforts to limit the spread of infections by travelers and migrants. The impacts of Northern ERID fears and vulnerabilities, inadequate publichealth services in impoverished places, and migration from the South also are explored in Chapter 6. The World Health Assembly’s International Health Regulations (IHRs) present confinement and human rights issues of further interest. The feasibility and advisability of quarantines (Fink, 2015; Onishi, 2014), isolation (Zuger, 2010), and social exclusion in a mobility-driven world receive attention along with limits on vaccine production and distribution and methods of determining the allocation of ventilators, intensive-care units, and other scarce resources (Fink, 2016). The role of enhanced clinics, surveillance (e.g., Walsh, 2011), and information technology is explored. The growing emphasis on responses centered around community participation reveals the changing face of global public health. Climate change, population dislocation, and human health Climatic variations have long triggered human migrations. In the contemporary period, human-induced climate change exacerbates pre-existing vulnerabilities (McMichael, Barnett, and McMichael, 2012, pp. 646–647). When living off the land becomes unimaginable and life becomes “increasingly intolerable,” climatedisplaced youth from Niger, Mali, and Chad, often encouraged by Facebook posts, join their conflict-driven contemporaries on the arduous journey north to Algeria and Libya. An unknown number die along the way; nearly 5,000 migrants perished trying to push across the Central Mediterranean in 2016 (Sengupta, 2016b, pp.A12–A13). In the words of William Swing (2017, p. vii), Director General of the International Organization for Migration (IOM), “we can no longer afford to ignore human mobility – constitutive of our time – in collective efforts to protect the future of our planet.” In this connection, the Paris Agreement adopted at the

22

Introduction

Conference of Parties to the United Nations Framework Convention on Climate Change (COP21) specifically references links between climate change and forced migration (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 95, 112–113). The critical importance of this interface is reflected in the charge of WHO’s Commission on Social Determinants of Health (2008, p. 1): “we need to bring the two agendas of health equity and climate change together.” Consideration of the global health vulnerabilities and possibilities of settled and dislocated populations in the wake of climate change provides a special focus for attention in Chapter 7. With particular reference to contemporary China, Transnational Mobility and Global Health is concerned with how the health risks and consequences associated with climatic change contribute to population movements (forced displacement, anticipatory migration, and planned resettlements) along with the health impacts of climatic displacement (also see McMichael, Barnett, and McMichael, 2012). Looking toward the future, Chapter 7 considers prospects that massive resettlement of ecological migrants will be required in the face of environmental impacts precipitated by climate change (e.g., sea-level rise) as well the likelihood that substantial proactive population flows will occur in anticipation of such developments and as a means of enhancing personal, family, or group health and well-being (Bardsley and Hugo, 2010). Will the health and well-being of persons internally and transnationally displaced by climate change and human-induced contributors to climate change be protected? Will migrant diasporas become influential actors in climate change mitigation and adaptation? Will countries that bear special responsibility for exacerbating climate change recognize the interconnected political, economic, and environmental drivers of migration and transform their entry systems accordingly (Mavroudi and Nagel, 2016, p. 145)? The global health implications of environmental migration and decisions by wealthy countries to attempt to forestall the arrival of climate migrants, or to accept them, receive special attention in Chapter 7.

Promising educational, research, and policy approaches The conclusion of the book is devoted to promising approaches that will redress unequal mobilities and the drivers of health and health-care disparities. Privilege and lack of privilege and the challenges of allocating available resources in ways that rectify injustice (see Walker, 2015) are highlighted as core challenges and organizing principles. Promoting equity “is our brightest hope for significantly improving global health” (Stewart, 2017, p. 118). Ethically and practically, Paul Farmer and colleagues (2013, p. 335) maintain that as long as health inequity across the world is perceived as a problem of the ‘other,’ of interest only to the few who feel motivated to help poor countries, then it is unlikely to gain the breadth and depth of engagement that will be required to address many of the problems we face. (also see Crisp, 2010, p. 15)

Introduction 23 The conclusion makes a case for, and explicitly elaborates pathways to, advancing “Us before Me” public-health ethics and approaches. People will continue to cross borders and boundaries both physically and virtually. Increasingly, “students and young professionals from developed and developing countries are moving in both directions, creating new networks of knowledge and practice” (Frenk, et al., 2010, p. 1947). Changing vicious to virtuous health cycles rests largely on education, preparation, and expanded access. The pathway to enhanced equity and inclusion incorporates strategic advocacy (see, for instance, Pottie and Gruner, 2016, pp. 337–339). Reverse innovation features in promising efforts to connect migration, health, and education. In Turning the World Upside Down, Crisp (2010, p. vii; also p. 12) persuasively demonstrates that, when global health is at stake, “we all have something to learn and all have something to teach.” Chapter 8 elaborates a proposal for robust, symmetrical, and TC-informed global-health education in North and South, for migrants as well as health practitioners.51 Transformed educational and research/outreach initiatives are essential if progress is to be made in addressing the pressing challenges of global health induced by unequal mobilities. In the face of these daunting challenges, Southern actors are expanding and enriching the global governance landscape and moving us toward a “multi-partner world” (Hillary Clinton quoted in Kickbusch and Ivanova, 2013, pp. 19–20) where health provides the common ground for deepening transnational ties. Symmetrical transnational partnerships and innovative health and E-health technologies further promise to enhance medical education and public-health capacity in the South (see, for instance, Murphy, et al., 2013, pp. 125–127; McCracken and Phillips, 2017, pp. 276–277). These developments are quickening at a time of expansion in the number of global health programs in the North and compelling reasons to link with higher-education institutions in the South (Herrick and Reubi, 2017, p. vii; Koehn and Obamba, 2014). The central importance of contextual, community-based research and decision making is emphasized in this connection. The global circulation of health expertise provides a promising pathway to rectifying unequal mobilities (see, for instance, Crisp, 2010, pp. 68, 204–206). Prospects that committed volunteers will inspire and catalyze community-health gains in the South are explored in-depth. This discussion first considers the limitations and potential of mounting volunteer short-term-medical-mission and service-learning experiences (Sykes, 2014; Brada, 2017). Then, launching a TCequipped Global Health and Migration Corps is proposed and justified. Systematic outcome and impact evaluations are needed to assess and inform policy interventions that address mobility and global health; they also serve as an essential component of viable transnational partnerships and collaborative ventures (see Koehn and Uitto, 2017, especially Chapter 9). A useful mobility-focused framework for evaluating early and long-term contributions includes patient-health outcomes (survival, recovery, restoration of function, wellness learning, resilience, changes in quality of life), health-provider outcomes (transnational competence, technical skills, physical and emotional health), community-health-infrastructural

24

Introduction

enhancements and sustainable-health outcomes, institutional transformation, and changes in out-migration patterns. Chapter 8 proposes and justifies an evaluation framework that encompasses these considerations and connects outcome and impact evaluation to global health’s current and coming mobility challenges. In its 2010 Global Consultation Report, the World Health Organization recognized that policies and strategies to manage the health consequences of migration have not kept pace with growing challenges related to the volume, speed, and diversity of modern migration, and they do not sufficiently address the existing health inequities, and determining factors of migrant health, including barriers to accessing health services. (WHO, 2010, p. 9) Proactive policy and partnering initiatives need to engage the drivers of transnational human mobility, the resulting conditions and health-care-access opportunities, and the need for coordinated adaptive approaches. For maximum effectiveness, “policy making will need to recognize the complexity and heterogeneity of migration – in terms of motivating factors and diversity in duration and destinations and in the [unequal] demographic and socioeconomic [and physical- and mental-health] characteristics of migrants” (McMichael, Barnett, and McMichael, 2012, p. 650). The conclusion to the book explores policy, advocacy, and normative prospects for advancing transnational-health equity in an age of mobility.

Notes 1 For Elina Penttinen and Anita Kynsilehto (2017, p. 12), “the concept of mobility embraces both physical and virtual mobilities that increasingly intersect.” 2 Anthony Elliot and John Urry (2010, p. 17) identify thirteen different kinds of contemporary mobility that engage specific sets of network capital. 3 The stay of a migrant can be permanent; “involve return; back-and-forth, circular movements between places; step-wise, onward movement from place to place over time; and the construction of simultaneous translocal/transnational worlds” (Lindley, 2014, p. 8; also Kapur and McHale, 2005, p. 9). 4 For students, Sharon Spray and Laura Roselle (2012, p. 117) suggest that “two important areas of research related to the movement of people are migration and health.” Specific issues related to both concerns that merit inquiry include state policies, international politics, humanitarian responses to emergency and crisis situations, security challenges, and migrant experiences (Spray and Roselle, 2012, pp. 117–119). All of these issues constitute foci of attention in this book. 5 It is particularly important for this study to recognize that the extended families of circular migrants “share health risks and determinants of migrant populations due to travel and cultural linkages” (WHO, 2010, p. 35). 6 Annual mass internal and external migrations include the Hajj and the tens of millions migrant workers in China who make an estimated three billion journeys home over the Lunar New Year (Buckley and Wu, 2017). 7 The practical suggestions set forth in this book have been informed, in part, by the projects assigned to and submitted by students enrolled in the courses on Politics of

Introduction 25

8

9 10 11

12 13

14 15

16 17 18 19 20 21 22 23

Global Migration and Issues in Global Public Health that I have the good fortune to teach at the University of Montana. Elliot and Urry (2010, pp. 105–105) aptly illustrate the hierarchy of mobility opportunity by reference to prevailing “global care chains,” whereby the labor benefits of emotional and physical caring are transferred “from those situated lower down the global care chain to those situated further up.” South-South labor migration is the focus on attention in the volume edited by Patricia Short, Moazzem Hossain, and M. Adil Khan (2017). In 2017, David Haines (2017, p. 63; also p. 64) reported that the United States experiences “nearly two hundred million land-border crossings each year from Canada and Mexico” although “many of these do not appear in formal visa statistics.” Including transnational adoptions, family formation/reunion, and commercial surrogacy (Penttinen and Kynsilehto, 2017, pp. 43–45). Penttinen and Kynsilehto add that cross-border marriages “have replaced, to an extent at least, traditional arranged marriages” (pp. 43–44). Roughly 25 million migrants from Sub-Saharan Africa “lived outside their countries of birth in 2017” (Connor, 2018). Moreover, requiring people who face persecution in the sending-country to prove “that they are not motivated in any way by economic needs” is “a nearly impossible task for those seeking asylum in wealthy countries” (Mavroudi and Nagel, 2016, p. 120). On the inconsistent treatment of asylum applications in the USA and regional disparities in approvals versus denials, see Jordan and Romero (2018). Syria is the country of origin for 12.5 million displaced persons, about one-fifth of the world total (Connor, 2016). Of course, many other people who have not been forcibly dislocated are domestically on the move or live outside the jurisdiction of their birth. Technically, undocumented migrants arrive (and stay) in a receiving-country by airplane, boat, or overland without a valid entry visa and irregular migrants arrive “with a legal visa either to visit [, study,] or work and overstay their visa without any residency status” (Cyril and Renzaho, 2016, p. 207). Including an estimated 11 million residing in the United States alone (Haines, 2017, p. 67). Women and their dependents account for the vast majority of refugees (Penttinen and Kynsilehto, 2017, p. 35). www.unhcr.org/en-us/refugees.html; accessed 2 January 2017. Also see Gladstone (2017b); Table 1 in Renzaho (2016, p. 125); Sengupta (2016a); and Mavroudi and Nagel (2016, p. 138). On specific global health inequities and the prevailing social/class gradient in exposure to health risks, see Ottersen, et al. (2014, p. 632) and Budrys (2017, pp. 182–185, 196). Thus, we are mainly working with the outer ring of Dahlgren and Whitehead’s classic illustration of the determinants of health (www.nwci.ie/download/pdf/determinants_ health_diagram.pdf; accessed 22 July 2016). Specifically, the Commission proposes the establishment of an independent UN Multistakeholder Platform on Global Governance for Health. For details, see Ottersen (2014, pp. 658–659). In the wake of SARS, for instance, China’s GDP declined by 0.5 percent (McNeil, 2017b). Genetic inheritance, socialization experiences, socio-behavioral decisions, and other individual factors play an important role in health and mobility decision-making. Health and mobility outcomes are multi-determined and “many so-called lifestyle behavioral ‘choices’ are rooted in the broad social and economic structural contexts and personal circumstances within which people live, and are not in any genuine sense free choices” (see McCracken and Phillips, 2017, pp. 67–68; emphasis in original).

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24 On global health governance and diplomacy, see Kickbusch, et al. (2013). 25 In the health arena, Kirton and Cooper (2009, p. 314) note that “within the central governments .  .  ., more departments are becoming involved, including the powerful departments for agriculture, finance, development, trade, foreign policy, national security, and national intelligence, as well as the traditionally low-ranking and isolated ones responsible for environment and for health” (also see McCracken and Phillips, 2017, pp. 62, 72; Kickbusch, et al., 2013, pp. 3–4). 26 On the deleterious influence of the World Bank and structural-adjustment programs on health in Southern countries, see Davies (2010, pp. 42–48). 27 On the expansion of corporate influence in global health governance, see Lee, Kenworthy, and MacKenzie (2016, pp. 1–4); MacKenzie and Hawkins (2016, pp. 28, 35–36); Suzuki and Moon (2016, pp. 74–84); and Holden and Hawkins (2016). 28 The Bill and Melinda Gates Foundation has “more financial resources at its disposal than WHO” (Davies, 2010, pp. 40, 52). 29 Accountable neither to shareholders nor to voters, “philanthropists and foundations can move boldly” (Callahan, 2017) without citizen recourse to the changes wrought through the clout exerted by their wealth in today’s malleable governance system. 30 The Global Fund, launched and financed by the G8, the Gates Foundation, other philanthropic donors, and a number of pharmaceutical companies, is “jointly managed by a UN and USAID chairperson” (Davies, 2010, pp. 52–53). The Global Fund emphasizes Southern participation and country ownership (Bartsch, 2009, pp. 131–133). 31 International Rescue Committee, Inc. at www.rescue.org/. 32 For a historical analysis of WHO leadership and the agency’s evolving priorities, see Davies (2010, pp. 37–41). 33 For examples of interagency collaboration on global health initiatives, see Renganathan (2013, p. 181) and Cooper (2013, p. 247). 34 WHO, “Migration and Health: Key Issues.” www.euro.who.int/en/health-topics/ health-determinants/migration-and-health/migrant-health-in-the-european-region/ migration-and-health-key-issues; accessed 30 May 2017. 35 Maria Thereza Alves’ floating gardens “explore human migration through the idea of seeds distributed inadvertently around the world in the holds of cargo ships.” (New York Times, 25 November 2016, p. C2). The jury citation in awarding Alves the New School’s 2016 Vera List Center Prize for Art and Politics recognized “her boldness in addressing, through art, urgent questions of resistance to homogenization of life itself ” (see www.newschool.edu/pressroom/pressreleases/2016/vlcawardmariatherezaalves.htm; accessed 3 December 2016). 36 Upstream contributors are distant “from the ultimate emergence of illness and disease but produce the social and economic inequalities between and within nations which underlie differing population health fortunes” (McCracken and Phillips, 2017, p. 70). 37 Border controls and immigration restrictions, for instance, “increase the costs and risks of migrating to wealthy countries” (Flahaux and De Haas, 2016, p. 4; also pp. 18–21). 38 Medical tourists from Africa “tend to be from the middle class as well as politicians and their extended families whose destinations vary with a significant number seeking treatment in Europe and the USA and an increasing number seeking treatment in Asia (e.g. India), the Middle East (e.g. Dubai) and in . . . South Africa” (Renzaho, 2016, p. 186). Affluent Chinese made an estimated half a million outbound medical trips in 2016 (Wee, 2017, p. B1). 39 However, Daniel Horsfall and Neil Lunt (2015b, pp. 25–27) point out that gaps often exist among “the prices advertised online, the price quoted to prospective medical tourists and the final price that is paid.” 40 Mosul continued to be the locus of multiple civilian casualties through 2017. On 1 June 2017, for instance, Islamic State fighters gunned down “at least 168 civilians, including women and children,” as they fled from armed conflict in the Shafa neighborhood (Comming-Bruce, 2017).

Introduction 27 41 In 2015 and 2016, Afghanistan experienced “about 240 attacks against health facilities or medical personnel” (Mashal and Abed, 2017). 42 Typically, women are particularly vulnerable at all stages of the migration process (see Bustamante, 2010, p. 91). 43 Including 6,000 Central Americans who died at the Mexico-United States border (Pottie, Hui, and Schneider, 2016, p. 292). 44 On the Kampala Convention for the protection of IDPs in Africa adopted at a 2009 summit meeting of the African Union, see Martin and Zetter (2012, pp. 27–29). 45 For instance, the prevailing narrow definition of what constitutes a “refugee” (evidence of individual persecution) increasingly serves as “a convenient excuse for countries in the Global North to deny refugee status to asylum seekers” who are displaced by war and conflict and to treat them “simply as undocumented immigrants” (Mavroudi and Nagel, 2016, p. 144). In Sweden, asylum seekers and rejected asylum seekers report “more symptoms of mental illness compared to any other group of immigrants” (Puthoopparambil, Ahlberg, and Bjerneld, 2015, p. 82). 46 The global and the local are in a constant state of “intense interaction” and “globalisation changes our experience of time and place as well as our value base and effects of our day to day actions” (Kickbusch, 1999, p. 451). 47 Worldwide remittances reached $600 billion in 2015 (Connor, 2016). 48 Among other public-health roles, NGOs “act as watchdogs of the pharmaceutical industry, advocate on behalf of primary healthcare and women’s health, and ensure that continuing attention is paid to community involvement and human rights in health matters around the globe” (Kickbusch and Buse, 2001, p. 719). 49 Including some 15,000 doctors from the seven Muslim-majority countries included in the Trump administration’s initial 2017 travel ban (McNeil, 2017c). 50 Brain waste refers to situations where skilled migrant-health professionals “are unable to find work in their area of expertise and end up working in unrelated low-paying jobs” (Kuehn, 2007, p. 1854). 51 In comprehensive and detailed fashion, the proposal elaborated in Chapter 8 addresses the Lancet Commission on Education of Health Professionals for the 21st Century’s call for transformative education to enhance health systems globally (see Frenk, et al., 2010).

References Almosawa, Shuaib; and Nordland, Rob. 2016. “Doctors Without Borders Withdraws Staff in Yemen.” New York Times, 19 August, p. A3. Angier, Natalie. 1998. “Man vs. Woman: In History’s Travel Olympics, There’s No Contest.” New York Times, 27 October. Appadurai, Arjun. 1996. Modernity at Large: Cultural Dimensions of Globalization. Minneapolis: University of Minnesota Press. Arango, Tim. 2016. “Told to Stay in Mosul, Civilians Are Dying in Flight.” New York Times, 24 November, pp. A1, A8. Astier M. Almedom. 2008. “Resilience Research and Policy/Practice Discourse in Health, Social, Behavioral, and Environmental Sciences over the Last Ten Years.” African Health Sciences 8 (December):S1–S13. Bambra, Clare; Fox, Debbie; and Scott-Samuel, Alex. 2005. “Towards a Politics of Health.” Health Promotion International 20 (2):187–193. Bardsley, Douglas K.; and Hugo, Graeme J. 2010. “Migration and Climate Change: Examining Thresholds of Change to Guide Effective Adaptation Decision-Making.” Population and Environment 32:238–262.

28

Introduction

Barmania, Sima; and Lister, Graham. 2013. “Civil Society Organizations, Global Health Governance and Public Diplomacy.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 253–267. Barnard, Anne; and Saad, Hwaida. 2016. “Life Is Turned ‘Upside Down’ as Bombing Escalates in Syria.” New York Times, 17 November, p. A10. Bartsch, Sonja. 2009. “Southern Actors in Global Public-Private Partnerships: The Case of the Global Fund.” In Health for Some: The Political Economy of Global Health Governance, edited by Sandra J. MacLean, Sherri A. Brown, and Pieter Fourie. New York: Palgrave Macmillan. Pp. 10–144. Berry-James, RaJade M. 2012. “Cultural Competency in Health Care: Standards, Practices, and Measures.” In Cultural Competency for Public Administrators, edited by Kristen A. Norman-Major and Susan T. Gooden. Armonk, NY: M.E. Sharpe. Pp. 181–196. Blouin, Chantal; Pearcey, Mark; and Percival, Valerie. 2013. “Instruments for Global Health Diplomacy in the UN System beyond the WHO.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 199–211. Brada, Betsey B. 2017. “Exemplary or Exceptional? The Production and Dismantling of Global Health in Botswana.” In Global Health and Geographical Imaginaries, edited by Clare Herrick and David Reubi. London: Routledge. Pp. 40–53. Buckley, Chris; and Wu, Adam. 2017. “The Lunar New Year in China: Inside the World’s Largest Holiday Rush.” New York Times, 27 January, p. A6. Budrys, Grace. 2017. Unequal Health: How Inequality Contributes to Health or Illness, 3rd edition. Boulder, CO: Rowman & Littlefield. Bustamante, Jorge. 2010. “Keynote Address.” In World Health Organization, Health of Migrants: The Way Forward. Report of a Global Consultation Held in Madrid, Spain, 3–5 March. Geneva: World Health Organization. Pp. 89–94. Cahill, Kevin M. 2017. Milestones in Humanitarian Action. New York: Fordham University Press. Callahan, David. 2017. “The Rising Power of Philanthropy.” New York Times, 20 June. Carens, Joseph H. 1996. “Aliens and Citizens: The Case for Open Borders.” In Theories of Migration, edited by Robin Cohen. Cheltenham, UK: Edward Elgar. Pp. 405–427. Carey, Benedict. 2018. “A Dicey Psychological Outlook for Migrant Children in Detention.” New York Times, 19 June, p. A15. Chen, Lincoln C.; and Berlinguer, Giovanni. 2001. “Health Equity in a Globalizing World.” In Challenging Inequities in Health: From Ethics to Action, edited by Timothy Evans, Margaret Whitehead, Finn Diderichsen, Abbas Bhuiya, and Meg Wirth. Oxford: Oxford University Press. Pp. 35–44. Chou, Meng-Hsuan; Kamola, Isaac; and Pietsch, Tamson. 2016. “Introduction: The Transnational Politics of Higher Education.” In The Transnational Politics of Higher Education: Contesting the Global/Transforming the Local, edited by Meng-Hsuan Chou, Isaac Kamola, and Tamson Pietsch. London: Routledge. Pp. 1–20. Cochrane, Emily. 2017. “Health Drove U.S. Envoys Out of Cuba.” New York Times, 11 August, p. A5. Comming-Bruce, Nick. 2017. “ISIS Killed 213 Civilians in Mosul, U.N. Says.” New York Times, 9 June, p. A10. Connell, John. 2010. Migration and the Globalisation of Health Care: The Health Worker Exodus? Cheltenham, UK: Edward Elgar. Connell, John. 2014. “The Two Cultures of Health Worker Migration: A Pacific Perspective.” Social Science and Medicine 116:73–81.

Introduction 29 Connor, Phillip. 2016. “International Migration: Key Findings from the U.S., Europe and the World.” Pew Research Center Fact Tank, 15 December. Connor, Phillip. 2018. “International Migration from Sub-Saharan Africa Has Grown Dramatically Since 2010.” Pew Research Center Fact Tank, 28 February. Cooper, Andrew F. 2013. “The G9/G20 and Global Health Governance: Extended Fragmentation or a New Hub of Coordination?” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 243–252. Crisp, Nigel. 2010. Turning the World Upside Down: The Search for Global Health in the 21st Century. London: Royal Society of Medicine Press. Crisp, Nigel. 2016. One World Health: An Overview of Global Health. Boca Raton, FL: CRC Press. Cyril, Sheila; and Renzaho, Andre M.N. 2016. “Invisible and Suffering: Prolonged and Systematic Detention of Asylum Seekers Living in Substandard Conditions in Greece.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 207–254. Dargis, Manohla. 2017. “Watching a Crisis, with No Calm in Sight.” New York Times, 13 October, p. C6. Davies, Sara. 2010. Global Politics of Health. Cambridge, UK: Polity Press. de Leon Siantz, Mary Lou. 2016. “Hispanic Immigration and the Epidemiological Paradox.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 345–361. Dickenson, Elliot. 2017. Globalization and Migration: A World in Motion. Boulder, CO: Rowman & Littlefield. Elliot, Anthony; and Urry, John. 2010. Mobile Lives. London: Routledge. Farmer, Paul. 2013. “Preface.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. xiii–xxiii. Farmer, Paul; Basilico, Matthew; Kerry, Vanessa; Ballard, Madeleine; Becker, Anne; Bukhman, Gene; Dahl, Ophelia; Ellner, Andy; Ivers, Louise; Jones, David; Meara, John; Mukherjee, Joia; Sievers, Amy; and Yamamoto, Alyssa. 2013. “Global Health Priorities for the Early Twenty-First Century.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 302–339. Fernandez, Manny. 2017. “A Northbound Path, Marked by More and More Bodies.” New York Times, 5 May, pp. A1, A22–A23. Fink, Sheri. 2015. “Ebola Crisis Passes, But Questions on Quarantine Persist.” New York Times, 2 December. Fink, Sheri. 2016. “Whose Lives Should Be Saved? Researchers Ask the Public.” New York Times, 21 August. Fink, Sheri; and Belluck, Pam. 2015. “One Year Later, Ebola Outbreak Offers Lessons for Next Epidemic.” New York Times, 22 March. Fisher, Jean. 2016. “Migration’s Silent Witnesses: Maria Thereza Alves’ Seeds of Change.” www.jeanfisher.com/migrations-silence-witnesses-maria-thereza-alves-seeds-change/; accessed 3 December 2016. Flahaux, Marie-Laurence; and De Haas, Hein. 2016. “African Migration: Trends, Patterns, Drivers.” Comparative Migration Studies 4:1–25. Frenk, Julio; Chen, Lincoln; Bhutta, Zulfiqar A.; Cohen, Jordan; Crisp, Nigel; Evans, Timothy; Fineberg, Harvey; Garcia, Patricia; Ke, Yang; Kelley, Patrick; Kistnasamy, Barry;

30

Introduction

Meleis, Afaf; Naylor, David; Pablos-Mendez, Ariel; Reddy, Srinath; Scrimshaw, Susan; Sepulveda, Jaime; Serwadda, David; and Zurayk, Huda. 2010. “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World.” Lancet 376 (4 December):1923–1958. Garrett, Laurie. 2001. “The Return of Infectious Disease.” In Plagues and Politics: Infectious Disease and International Policy, edited by Andrew T. Price-Smith. London: Palgrave Macmillan. Pp. 183–194. Gladstone, Rick. 2016. “Casualties from Land Mines Soar by 75% Despite Treaty.” New York Times, 23 November, p. A8. Gladstone, Rick. 2017a. “Casualties Surge from Land Mines and Improvised Explosives.” New York Times, 15 December, p. A6. Gladstone, Rick. 2017b. “Displaced Population Hit Record in ‘16, U.N. Says.” New York Times, 19 June, p. A5. Glasgow Sara M.; and Pirages, Dennis. 2001. “Microsecurity.” In Plagues and Politics: Infectious Disease and International Policy, edited by Andrew Price-Smith. London: Palgrave Macmillan. Pp. 195–213. Gordon, Michael R. 2017. “Report Rebuts Russia’s Claim of Restraint in Bombing of Aleppo.” New York Times, 13 February, p. A6. Green, Jesse. 2017. “In Search of Home: Nigerians Come to America Onstage, Carrying Refreshingly Different Perspectives and Baggage.” New York Times, 17 May, pp. C1, C5. Gunn, S. Wiliiam A. 2010. “The Humanitarian Imperative in Major Health Crises and Disasters.” In Understanding the Global Dimensions of Health, edited by S.W.A. Gunn. New York: Springer. Pp. 159–168. Gushulak, Brian; and MacPherson, Douglas W. 2006. “The Basic Principles of Migration Health: Population Mobility and Gaps in Disease Prevalence.” Emerging Themes in Epidemiology 3 (3). DOI: 10.1186/1742-7622-3-3 Hadler, Max W. 2015. “Migration and Patient Mobility in Latin America.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 313–332. Haines, David W. 2017. Immigration Structures and Immigrant Lives: An Introduction to the US Experience. Lanham, MD: Rowman & Littlefield. Hancock, John. 2013. “Global Trade and Health Diplomacy: Maximizing Cooperation and Minimizing Conflict through Coherent International Rules.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 155–171. Harman, Sophie. 2012. Global Health Governance. London: Routledge. Harris, Gardiner. 2018. “25th Person at Embassy in Cuba Is Ill.” New York Times, 22 June, p. A10. Hein, Wolfgang. 2013. “The New Dynamics of Global Health Governance.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 55–72. Herrick, Clare. 2016. “Global Health, Geographical Contingency, and Contingent Geographies.” Annals of the American Association of Geographers 106 (3):672–687. Herrick, Clare; and Reubi, David. 2017. “Introduction.” In Global Health and Geographical Imaginaries, edited by Clare Herrick and David Reubi. London: Routledge. Pp. vii–xxviii. Heymann, David L.; and Chand, Sudeep. 2013. “Diplomacy and Global Health Security.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 125–139.

Introduction 31 Holden, Chris; and Hawkins, Benjamin. 2016. “Health Policy, Corporate Influence and Multi-Level Governance: The Case of Alcohol Policy in the European Union.” In Case Studies on Corporations and Global Health Governance: Impacts, Influence and Accountability, edited by Nora J. Kenworthy, Ross MacKenzie, and Kelley Lee. London: Rowman & Littlefield. Pp. 143–157. Horsfall, Daniel; and Lunt, Neil. 2015. “Medical Tourism by Numbers.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 25–36. Hossain, Moazzem; Khan, M. Adil; and Short, Patricia. 2017. “An Overview of SouthSouth Migration: Opportunities, Risks and Policies.” In South-South Migration: Emerging Patterns, Opportunities and Risks, edited by Patricia Short, Moazzem Hossain, and M. Adil Khan. London: Routledge. Pp. 1–10. Huang, Yanzhong. 2009. “In-Flew-Enza: Pandemic Influenza and Its Security Implications.” In Innovation in Global Health Governance: Critical Cases, edited by Andrew F. Cooper and John J. Kirton. Burlington, VT: Ashgate. Pp. 129–152. Huang, Yanzhong. 2016. “How to Reform the Ailing World Health Organization.” Council on Foreign Relations Expert Brief, 3 May. www.cfr.org/expert-brief/how-rerformailing-world-health-organization; accessed 24 April 2018. Ionesco, Dina; Mokhnacheva, Daria; and Gemenne, Francois. 2017. The Atlas of Environmental Migration. London: Routledge. Ives, Mike. 2016. “Study Finds Medical Bias against a Muslim Group.” New York Times, 6 December, p. A6. Jamison, Dean T.; and 24 co-authors. 2013. “Global Health 2035: A World Converging within a Generation.” Lancet 382:1898–1955. Janes, Craig R. 2003. “Criticizing with Impunity? Bridging the Widening Gulf between Academic Discourse and Action Anthropology in Global Health.” Social Analysis: The International Journal of Social and Cultural Practice 47, No. 1 (Spring):90–95. Johnson, Oliver; Bailey, Sarah L.; Willott, Chris; Crocker-Buque, Tim; Jessop, Vanessa; Birch, Marion; Ward, Helen; and Yudkin, John S. 2012. “Global Health Learning Outcomes for Medical Students in the UK.” Lancet 379 (2 June):2033–2035. Jordan, Miriam; and Romero, Simon. 2018. “Fleeing to U.S. Is Often Perilous: Getting Asylum? Precarious.” New York Times, 3 May, p. A11. Kamara, Joseph; and Renzaho, Andre M.N. 2016. “The Social and Health Dimensions of Refugees and Complex Humanitarian Emergencies.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 73–122. Kamradt-Scott, Adam. 2015. Managing Global Health Security: The World Health Organization and Disease Outbreak Control. New York: Palgrave Macmillan. Kapur, Devesh; and McHale, John. 2005. Give Us Your Best and Brightest: The Global Hunt for Talent and Its Impact on the Developing World. Washington, DC: Center for Global Development. Kickbusch, Ilona. 1999. “Global + Local = Glocal Public Health.” Journal of Epidemiology and Public Health 53:451–452. Kickbusch, Ilona. 2015. “The Political Determinants of Health: 10 Years On.” British Medical Journal 350:h81. Kickbusch, Ilona. 2017. “The New Director General of WHO and the Politics of Global Health.” BMJ Opinion, 31 May. Kickbusch, Ilona; and Buse, Kent. 2001. “Global Influences and Global Responses: International Health at the Turn of the Twenty-First Century.” In International Public Health:

32

Introduction

Diseases, Programs, Systems, and Policies, edited by Michael H. Merson, Robert E. Black, and Anne J. Mills. Gaithersburg: Aspen Publishers. Pp. 701–732. Kickbusch, Ilona; and Ivanova, Margarita. 2013. “The History and Evolution of Global Health Diplomacy.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 11–26. Kickbusch, Ilona; Lister, Graham; Told, Michaela; and Drager, Nick. 2013. “Global Health Diplomacy: An Introduction.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 1–9. Kickbusch, Ilona; and Rosskam, Elle. 2012. “Introduction: The Art and Practice of Conducting Global Health Negotiations in the 21st Century.” In Negotiating and Navigating Global Health: Case Studies in Global Health Diplomacy, edited by Ellen Rosskam and Ilona Kickbusch. London: World Scientific. Pp. 1–8. Kirton, John J.; and Cooper, Andrew F. 2009. “Innovation in Global Health Governance.” In Innovation in Global Health Governance: Critical Cases, edited by Andrew F. Cooper and John J. Kirton. Burlington, VT: Ashgate. Pp. 309–340. Koehn, Peter H. 1991. Refugees from Revolution: U.S. Policy and Third-World Migration. Boulder, CO: Westview Press. Koehn, Peter H. 2007. “Global Health and Human Rights: Challenges for Public-Health Administrators in an Era of Interdependence and Mobility.” In Handbook of Globalization, Governance, and Public Administration, edited by Ali Farazmand and Jack Pinkowski. Boca Raton, FL: CRC Press. Pp. 1045–1073. Koehn, Peter H.; and Obamba, Milton O. 2014. The Transnationally Partnered University: Insights from Research and Sustainable Development Collaborations in Africa. Gordonsville, VA: Palgrave Macmillan. Koehn, Peter H.; and Rosenau, James N. 2010. Transnational Competence: Empowering Professional Curricula for Horizon-Rising Challenges. Boulder, CO: Paradigm Publishers. Koehn, Peter H.; and Uitto, Juha I. 2017. Universities and the Sustainable Development Future: Evaluating Higher-Education Contributions to the 2030 Agenda. London: Routledge. Kohut, Meridith; and Herrera, Isayen. 2017. “As Venezuela Collapses, Children Die of Hunger.” New York Times, pp. F2–F12. Koplan, Jeffrey P.; Bond, T. Christopher; Merson, Michael H.; Reddy, K. Sriath; Rodriguez, Mario H.; Sewankambo, Nelson K.; and Wasserhelt, Judith N. 2009. “Towards a Common Definition of Global Health.” Lancet 383, No. 9679 (6 June):1993–1995. Koser, Khalid; and Martin, Susan. 2011. “The Migration-Displacement Nexus.” In The Migration-Displacement Nexus: Patterns, Processes, and Policies, edited by Khalid Koser and Susan Martin. New York: Berghahn Books. Pp. 1–13. Kuehn, Bridget. 2007. “Global Shortage of Health Workers, Brain Drain Stress to Developing Countries.” JAMA 298 (16):1853–1855. Labonte, Ronald. 2013. “Human Rights and Equity: The Value Base of Global Health Diplomacy.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 89–105. La Gorce, Tammy. 2017. “The Downside of Business Travel: It Makes Us Sicker.” New York Times, 28 November, p. B4. Land, Anthony. 2017. “MIHA.” In Milestones in Humanitarian Action, edited by Kevin M. Cahill. New York: Fordham University Press. Pp. 126–128.

Introduction 33 Leder, Karin; Torresi, Joseph; Libman, Michael D.; Cramer, Jakob P.; Castelli, Francesco; Schlagenhauf, Patricia; Wilder-Smith, Annelies; Wilson, Mary E.; Keystone, Jay S.; Schwartz, Eli; Barnett, Elizabeth D.; von Sonnenburg, Frank; Brownstein, John S.; Cheng, Allen C.; Sotir, Mark J.; Esposito, Douglas H.; and Freedman, David O. 2013. “GeoSentinel Surveillance of Illness in Returned Travellers, 2007–2011.” Annals of Internal Medicine 158:456–468. Lee, Kelley; Kenworthy, Nora J.; and MacKenzie, Ross. 2016. “Introduction.” In Case Studies on Corporations and Global Health Governance: Impacts, Influence and Accountability, edited by Nora J. Kenworthy, Ross MacKenzie, and Kelley Lee. London: Rowman & Littlefield. Pp. 1–7. Lencucha, Raphael; and Mohindra, Katia. 2014. “A Snapshot of Global Health Education in North American Universities.” Global Health Promotion 21 (1):63–67. Lindley, Anna. 2014. “Exploring Crisis and Migration: Concepts and Issues.” In Crisis and Migration: Critical Perspectives, edited by Anna Lindley. London: Routledge. Pp. 1–23. Lindley, Anna; and Hammond, Laura. 2014. “Histories and Contemporary Challenges of Crisis and Mobility in Somalia.” In Crisis and Migration: Critical Perspectives, edited by Anna Lindley. London: Routledge. Pp. 46–72. Londono, Ernesto. 2017. “Closing the Door on Cuban Immigrants.” New York Times, 6 October, p. A4. Lunt, Neil; Horsfall, Daniel; and Hanefeld, Johanna. 2015. “The Shaping of Contemporary Medical Tourism and Patient Mobility.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 3–15. Lyttleton, Chris. 2014. Intimate Economies of Development: Mobility, Sexuality and Health in Asia. London: Routledge. MacKenzie, Ross; and Hawkins, Benjamin. 2016. “Medicalization and Commodification of Smoking Cessation: The Role of Industry Actors in Shaping Health Policy.” In Case Studies on Corporations and Global Health Governance: Impacts, Influence and Accountability, edited by Nora J. Kenworthy, Ross MacKenzie, and Kelley Lee. London: Rowman & Littlefield. Pp. 27–40. Mackey, Tim K.; and Liang, Bryan A. 2013. “Restructuring Brain Drain: Strengthening Governance and Financing for Health Worker Migration.” Global Health Action 6 (19923). MacLean, Sandra J.; and Brown, Sherri A. 2009. “Introduction: The Social Determinants of Global Health: Confronting Inequities.” In Health for Some: The Political Economy of Global Health Governance, edited by Sandra J. MacLean, Sherri A. Brown, and Pieter Fourie. New York: Palgrave Macmillan. Pp. 3–17. Manjoo, Farhad. 2016. “A Shared Lifeline for Millions of Migrants.” New York Times, 22 December, pp. B1, B7. Marfleet, Philip; and Hanieh, Adam. 2014. “Migration and ‘Crisis’ in the Middle East and North Africa Region.” In Crisis and Migration: Critical Perspectives, edited by Anna Lindley. London: Routledge. Pp. 24–45. Martin, Susan F.; and Zetter, Roger. 2012. “Forced Migration: The Dynamics of Displacement and Response.” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 13–46. Mashal, Mujib; and Abed, Fahim. 2017. “After Kabul Hospital Attack, ‘Everywhere Was Full of Blood’.” New York Times, 9 March, p. A10. Mau, Steffen; and Mewes, Jan. 2009. “Class Divides within Transnationalisation: The German Population and Its Cross-Border Practices.” In Mobilities and Inequality, edited

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by Timo Ohnmacht, Hanja Maksim, and Manfred M. Bergman. Burlington, VT: Ashgate. Pp. 165–185. Mavroudi, Elizabeth; and Nagel, Caroline. 2016. Global Migration: Patterns, Processes, and Politics. London: Routledge. McCoy, Terrence. 2014. “How Deforestation Shares the Blame for the Ebola Epidemic.” Washington Post, 8 July. McCracken, Kevin; and Phillips, David R. 2017. Global Health: An Introduction to Current and Future Trends. London: Routledge. McMichael, Celia; Barnett, Jon; and McMichael, Anthony J. 2012. “An Ill Wind? Climate Change, Migration, and Health.” Environmental Health Perspectives 120, No. 5 (May):646–654. McNeil, Donald G., Jr. 2017a. “A Quest to Lead the W.H.O.” New York Times, 4 April, pp. D1, D3. McNeil, Donald G., Jr. 2017b. “Ready for a Pandemic? Only Six Nations Know.” New York Times, 1 August, p. D4. McNeil, Donald G., Jr. 2017c. “Travel Ban, Aimed at Terrorists, Touches Doctors in Hardto-Fill Jobs.” New York Times, 7 February, p. A12. Migdal, Joel S. 2004. “Mental Maps and Virtual Checkpoints: Struggles to Construct and Maintain State and Social Boundaries.” In Boundaries and Belonging: States and Societies in the Struggle to Shape Identities and Local Practices, edited by Joel S. Migdal. Cambridge: Cambridge University Press. Pp. 3–23. Moran, Michael. 2009. “Philanthropic Foundations and Global Health Partnership Formation: The Rockefeller Foundation and IAVI.” In Health for Some: The Political Economy of Global Health Governance, edited by Sandra J. MacLean, Sherri A. Brown, and Pieter Fourie. New York: Palgrave Macmillan. Pp. 118–129. Murphy, Jill; Neufeld, Victor R.; Demissie Habte; Abraham Asseffa; Afsana, Kaosar; Kumar, Anant; Larrea, Maria de Lourdes; and Hatfield, Jennifer. 2013. “Ethical Considerations in Global Health Partnerships.” In An Introduction to Global Health Ethics, edited by Andrew D. Pinto and Ross E.G. Upshur. London: Routledge. Pp. 117–128. Neath, Rupert. 2017. “World’s Witnessing a New Gilded Age as Billionaires’ Wealth Swells to $6tn.” Guardian, 26 October. Nwadiuko, Joseph; James, Keyonie; Switzer, Galen E.; and Stern, Jamie. 2016. “Giving Back: A Mixed Methods Study of the Contributions of US-Based Nigerian Physicians to Home Country Health Systems.” Globalization and Health 12:33. Ohnmacht, Timo; Maksim, Hanja; and Bergman, Manfred M. 2009. “Mobilities and Inequality: Making Connections.” In Mobilities and Inequality, edited by Timo Ohnmacht, Hanja Maksim, and Manfred M. Bergman. Burlington, VT: Ashgate. Pp. 7–25. Olsson, Eva-Karin; and Zhong, Kaibin. 2012. “Transboundary Crisis Management: Implications for Research and Practice.” In SARS from East to West, edited by Eva-Karin Olsson and Lan Xue. Boulder, CO: Lexington Books. Pp. 226–248. Onishi, Norimitsu. 2014. “Clashes Erupt as Liberia Sets a Quarantine.” New York Times, 21 August, p. A1. Onishi, Norimitsu. 2017. “In an Angolan Town, Land Mines Still Lurk ‘Behind Every Bush’.” New York Times, 27 April, p. A4. Onishi, Norimitsu; and Mouawad, Jad. 2014. “Journey Illustrates How Global Travel Is Open to the Spread of Disease.” New York Times, 3 October, p. A15. Ottersen, Ole P.; and 23 co-authors. 2014. “The Political Origins of Health Inequity: Prospects for Change.” Lancet 383 (15 February):630–667.

Introduction 35 Palinkas, Lawrence A.; Pickwell, Sheila M.; Brandstein, Kendra; Clark, Terry J.; Hill, Linda L.; Moser, Robert J.; and Osman, Abdikadir. 2003. “The Journey to Wellness: Stages of Refugee Health Promotion and Disease Prevention.” Journal of Immigrant Health 5, No. 1 (January):19–28. Pennings, Guido. 2015. “Ethics of Medical Tourism.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 341–349. Penttinen, Elina; and Kynsilehto, Anita. 2017. Gender and Mobility: A Critical Introduction. London: Rowman & Littlefield. Pottie, Kevin; and Gruner, Doug. 2016. “Health Equity: Evidence-Based Guidelines, E-Learning and Physician Advocacy for Migrant Populations in Canada.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 329–343. Pottie, Kevin; Hui, Chuck; and Schneider, Fabien. 2016. “Women, Children and Men Trapped in Unsafe Corridors.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 291–303. Puthoopparambil, Soorei J.; Ahlberg, Beth M.; and Bjerneld, Magdalena. 2015. “‘A Prison with Extra Favors’: Experiences of Immigrants in Swedish Detention Centres.” International Journal of Migration, Health and Social Care 11 (2):73–85. Rahman, Khaleda. 2018. “Police Officer Cradles the Body of a Little Boy Who Drowned Trying to Cross to Greece after His Boat Overturned as Turkish Authorities Search for More Migrants from the Doomed Craft.” Daily Mail, 13 February. Renganathan, Elil. 2013. “The World Health Organization as a Key Venue for Global Health Diplomacy.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 173–185. Renzaho, Andre M.N. 2016. “Health, Social and Economic Impact of Voluntary Migration.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 123–203. Rubin, Alissa J.; and Saad, Hwaida. 2016. “Bombs Damage Hospitals in Rebel-Held Aleppo, Halting Care.” New York Times, 21 November, p. A4. Satyen, Lata; Toumbourou, John W.; Mellor, David; Secer, Ilmiye; and Ghayour-Minaie, Matin. 2016. “Migrant Health in the Workplace: A Multi-Country Comparison.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 479–507. Schenker, Marc B. 2014. “Introduction.” In Migration and Health: A Research Methods Handbook, edited by Marc B. Schenker, Xochitl Castaneda, and Alfonso RodriguezLainz. Berkeley: University of California Press. Pp. 3–11. Scott, Courtney; Carriedo, Angela; and Knai, Cecile. 2016. “The Influence of the Food Industry on Public Health Governance: Insights from Mexico and the United States.” In Case Studies on Corporations and Global Health Governance: Impacts, Influence and Accountability, edited by Nora J. Kenworthy, Ross MacKenzie, and Kelley Lee. London: Rowman & Littlefield. Pp. 41–51. Sengupta, Somini. 2016a. “Record 65 Million People Displaced, U.N. Says.” New York Times, 20 June, p. A3. Sengupta, Somini. 2016b. “‘Road on Fire’ for Men Fleeing Drought and War.” New York Times, 16 December, pp. A1, A12–A13.

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Sengupta, Somini. 2017. “Despite a U.N. Resolution, Attacks Continue on Medical Personnel in War Zones.” New York Times, 26 May, p. A4. Sheikh, Kabir; Schneider, Helen; Agyepong, Irene A.; Lehmann, Uta; and Gilson, Lucy. 2016. “Boundary-Spanning: Reflections on the Practices and Principles of Global Health.” BMJ Global Health 1. DOI: 10.1136/bmjgh-2016-000058 Sheikh, Mubashar; and Afzal, Muhammad M. 2012. “Global Health Workforce Alliance: Negotiating for Access to Health Workers for All.” In Negotiating and Navigating Global Health: Case Studies in Global Health Diplomacy, edited by Ellen Rosskam and Ilona Kickbusch. London: World Scientific. Pp. 297–324. Short, Patricia; Hossain, Moazzem; and Khan, M. Adil (eds.). 2017. South-South Migration: Emerging Patterns, Opportunities and Risks. London: Routledge. Skeldon, Ronald. 1997. Migration and Development: A Global Perspective. Essex, UK: Longman. Smith, Craig S. 2017. “Offering a Path to Citizenship, Canada Beckons Foreign Students.” New York Times, 27 January, p. A4. Sorensen, Martin S. 2016. “Abuses of Young Refugees in Denmark Mirror Perils across Europe.” New York Times, 20 December, p. A4. Spray, Sharon; and Roselle, Laura. 2012. Research and Writing in International Relations, 2nd edition. Boston: Longman. Stewart, Kearsley A. 2017. “Anthropological Perspectives in Bioethics.” In International Encyclopedia of Public Health, 2nd edition, edited by Stella R. Quah. Amsterdam: Academic Press. Pp. 113–121. Stoneking, Mark. 1998. “Women on the Move.” Nature Genetics 20:219–220. Suzuki, Elina; and Moon, Suerie. 2016. “Informal Channels of Corporate Influence on Global Health Policymaking: A Mapping of Strategies across Four Industries.” In Case Studies on Corporations and Global Health Governance: Impacts, Influence and Accountability, edited by Nora J. Kenworthy, Ross MacKenzie, and Kelley Lee. London: Rowman & Littlefield. Pp. 73–88. Swing, William L. 2017. “Supporting Environmental Migrants: A New Imperative.” Foreword to The Atlas of Environmental Migration, edited by Dina Ionesco, Daria Mokhnacheva, and Francois Gemenne. London: Routledge. Pp. vi–vii. Sykes, Kevin J. 2014. “Short-Term Medical Trips: A Systematic Review of the Evidence.” Systematic Review 104 (7):e38–e48. Tatem, Andrew J.; and Smith, David L. 2010. “International Population Movements and Regional Plasmodium Falciparum Malaria Elimination Strategies.” Proceedings of the National Academy of Sciences 107 (27):12222–12227. Toole, Michael. 2006. “Forced Migrants: Refugees and Internally Displaced Persons.” In Social Injustice and Public Health, edited by Barry S. Levy and Victor W. Sidel. Oxford: Oxford University Press. Pp. 190–204. Upshur, Ross E.G.; Benatar, Solomon; and Pinto, Andrew D. 2013. “Ethics and Global Health.” In An Introduction to Global Health Ethics, edited by Andrew D. Pinto and Ross E.G. Upshur. London: Routledge. Pp. 16–35. Villa-Torres, Laura; Gonzalez-Vazquez, Tonatiuh; Fleming, Paul J.; Gonzalez-Gonzalez, Edgar L.; Infante-Xibille, Cesar; Chavez, Rebecca; and Barrington, Clare. 2017. “Transnationalism and Health: A Systematic Literature Review on the Use of Transnationalism in the Study of the Health Practices and Behaviors of Migrants.” Social Science and Medicine 183:70–79. Walker, Darren. 2015. “Why Giving Back Is Not Enough.” New York Times, 18 December, p. A39. Walsh, Bryan. 2011. “Virus Hunter.” Time, 7 November, pp. 36–39.

Introduction 37 Walton-Roberts, Margaret. 2015. “Migration: The Mobility of Patients and Health Professionals.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 238–246. Wee, Sui-lee. 2017. “Life-or-Death Medical Tourism.” New York Times, 30 May, pp. B1, B3. World Health Organization (WHO). 2010. Health of Migrants: The Way Forward. Report of a Global Consultation Held in Madrid, Spain, 3–5 March. Geneva: World Health Organization. World Health Organization (WHO), Commission on Social Determinants of Health. 2008. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: World Health Organization. Zhou, Yanqiu R.; Coleman, William D.; Huang, Yingying; Sinding, Christina; Su, Helen H.; Wei, Wei; Gahagan, Jacqueline; and Micollier, Evelyne. 2017. “Exploring the Intersections of Transnationalism, Sexuality and HIV Risk.” Culture, Health & Sexuality 19 (6):645–652. Zuger, Abigail. 2010. “Isolation, an Ancient and Lonely Practice, Endures.” New York Times, 31 August, p. D5.

1

Transnational travel as health insurance

Human migration and global health are connected in multiple and diverse ways. Some people cross borders for reasons not directly related to health, bringing along their care needs, vulnerabilities, and any hitchhiking pathogens. Others deliberately venture and invest outward in search of desired remedies or health care. Both movements are captured under the construct “transnational care”1 and require attention in a book concerned with transnational mobility and global health.2 Transnational medical travel as a recognized, informal, or de facto form of health insurance for some people constitutes a growing manifestation of unequal mobilities. In the case of Mexican Americans who utilize health services for themselves or dependents in both Mexico and California, actual cross-border health insurance is available and bi-national plans are under consideration (Bustamante, 2015). Health-system coverage and insurance options also exist for cross-border migrants in the European Union (see Legido-Quigley and McKee, 2015). South Africa has forged bilateral agreements with 18 countries, including Mozambique, Botswana, Lesotho, and Zimbabwe, that enable their citizens “to access specialized medical treatments in South Africa at subsidized rates” (Crush, et al., 2015, p. 327). Chapter 1 first treats traveler care. Then, we move on to explore the rising popularity of transnational mobility undertaken specifically for health-care reasons.3 In contrast to the subsequent chapters, which focus on less-privileged migrants, we open here with the other side of the unequal mobility coin: movements that predominantly feature relatively well-off patients.

Travelers’ health care Transnational tourism has become ever more popular and feasible; today, it is a huge business operation, with more than one billion tourists crossing national borders annually (Mavroudi and Nagel, 2016, p. 8). With few health checks along the way, more tourists travel internationally than “permanent migrants, asylum seekers, refugees, returned refugees, IDPs, and migrant workers added together” (Davies, 2010, p. 101). Long-distance travel involving countries in Africa and Asia has grown particularly rapidly (Leder, et al., 2013, p. 456).4

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The role of tourism in infectious-disease transmission “too often” is “overlooked” (Davies, 2010, p. 101). In one indicative study, “a Boston-area survey found that about half of international travelers experienced health problems, 7% sought medical care, and 1% required hospitalization” (Chen and Wilson, 2013, p. 1753; also Hodges and Kimball, 2012, p. 117). On the other hand, in spite of the risks of infection, and transmission upon return home, associated with the crowded conditions that prevail during the annual short-term Hajj migration to Mecca, “there have been no major Hajj-related disease outbreaks in recent years” (McCracken and Phillips, 2017, p. 312). Students who are touring or studying abroad comprise one stream of contemporary transnational mobility possessing health vulnerabilities. Adults who work abroad or volunteer for international educational travel “adventures” are an increasing mobility cohort (Weed, 2018). Although opportunities for pre-travel consultations, travel-health education, and updating immunizations usually are available at student-health centers5 and local clinics in the North, both sets of travelers too often overlook these resources (Leder, et al., 2013, p. 466). People, particularly Southern-born persons and their Northern-born children who visit friends and relatives in origin places, account for a major proportion of trips abroad and the contraction of high-risk infectious diseases (Angell and Cetron, 2005, pp. 67–68). Among travelers who cross health-condition divides to visit, pre-departure barriers to the delivery of preventative-health services and advice include inaccurate traveler perceptions of low personal risk or threat6 leading to failure to seek precautionary advice (see, for instance, Brody, 2016) and secure necessary vaccinations, lack of insurance coverage, and inadequate knowledge of travel medicine and absence of transnational competency on the part of Northern providers (Angell and Cetron, 2005, pp. 68–70; Leder, et al., 2013, pp. 459, 465–466). Because they often engage in local and unfamiliar health-related behavior, “travelers visiting friends and relatives . . . are emerging as a group at substantial risk of travel illness” (Leder, et al., 2013, p. 456). Jill Hodges and Ann Marie Kimball (2012, p. 120) note that “travelers who are visiting friends and family tend to be at higher risk because they’re more likely to stay longer, visit remote areas and consume local food and water, and less likely to take precautions.” Lack of awareness of potential health risks in unfamiliar environments (Davies, 2010, p. 101) and treatment by local medical and dental providers can compound these risks (Angell and Cetron, 2005, p. 68). With 53 specialized travel or tropical-medicine clinical sites located around the world, GeoSentinel is uniquely situated to report on the incidence of traveler illnesses and diseases. Analysis of anonymous GeoSentinel data from patients who presented on return from travel between 2007 and 2011 provides insights into travel-health patterns. Among all travelers, gastrointestinal infections were most common, followed by febrile illness (mainly malaria and dengue) and dermatological problems. A majority of the returned travelers acquired their health problem in Asia or Sub-Saharan Africa (Leder, et al., 2013, pp. 456–458). Analysis by travel reason reveals that tourists and students are most likely to incur gastrointestinal illnesses. Tourists also present with a high proportion

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of dermatological problems and a low proportion of febrile diseases. Overseas backpackers are contributing to the spread of antimicrobial resistance (Whiting, 2017). In contrast, persons visiting friends and relatives are particularly prone to contract febrile diseases and less likely to present with dermatological problems. Among students, neurologic as well as gastrointestinal diagnoses were particularly common and febrile illness less common.7 Among all travelers, “microbes may hitch a ride back to the home of the patient, potentially introducing new and unknown bacteria into the community or clinic where the patient next seeks care” (Hodges and Kimball, 2012, p. 115).

Medical tourism in North and South Medical tourists or international medical travelers (see Bell, et al., 2015, p. 285) are children,8 women, and men who journey to a foreign land for the specific purpose of securing health-promoting services.9 An individual’s intent-based transnational travel for medical purposes can be elective or obligatory; in the latter case, place-of-origin treatment is not available or illegal (Jones and Keith, 2006, p. 251; Connell, 2015, p. 22; Turner and Hodges, 2012, p. 9).10 In the face of perceived cost, expertise, time, and insurance coverage shortcomings associated with exclusive in-country health care (Connell, 2015, pp. 21–22), transnationalhealth outsourcing has become an increasingly popular option across the planet. For revenue-generation purposes, Southern government and private entities in countries like Thailand and India actively compete for health tourists among prospect patients from the North (Supakankunti, 2014, p. 680; Frenk, et al., 2010, p. 1949; Chanda, 2015).11 Spurred by daily access to “internet sources of information and imagery” (Lunt, Horsfall, and Hanefeld, 2015b, p. 12; also p. 10; also see Cheung, 2015, pp. 138–139; Gan and Frederick, 2015, p. 144; Horsfall and Lunt, 2015a; Holliday and Bell, 2015, pp. 423–424), individuals and families are attracted by and connecting with foreign providers.12 Neil Lunt, Daniel Horsfall, and Johanna Hanefeld (2015b, p. 8) assert that at the heart of the growth in medical tourism lies commercialization and in some part this is premised on the availability of web-based resources to furnish the consumer with information, imagery, and market destinations, and to connect consumers with an array of healthcare providers and brokers. Health tourism markets are mediated by the informal networks – including web fora, connected clinicians, and personal recommendations by family, friends, and acquaintances – that influence patient choice of destination and provider as well as treatment itineraries (Hanefeld, et al., 2015, pp. 356, 362; Bochaton, 2015a). This section identifies the motivations, principal source places, popular treatments, and diverse approaches favored by health tourists. Factors determining transnational access to elective care are analyzed in terms of social determinants and policy facilitators and constraints. Medical tourism both influences and is

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influenced by conditions of global and domestic inequality. The impact of medical outsourcing on population-health care in Southern-treatment countries merits particular attention in the context of unequal mobilities. Popular treatments, source places, and patient motivations With more than 100 million persons crossing borders in search of health benefits (Jones and Keith, 2006, p. 252), medical tourism takes on the characteristics of big business. Particularly appealing low-cost Southern services include “dentistry, cosmetic surgery, and increasingly advanced medical and surgical procedures” (Frenk, et al., 2010, p. 1949; also Holliday and Bell, 2015; Chanda, 2015). In Thailand, the appeal of medical tourism has shifted from the original emphasis on alternative medicine (e.g., herbal treatments, spas, traditional massages) to “niche markets in elective medical procedures, such as plastic surgery” carried out at private hospitals (Supakankunti, 2014, p. 680; also see Noree, 2015). Countries in South and Central America and the Caribbean are expanding from cosmetic surgery, dental treatment, and drug and alcohol rehabilitation into additional health services (Lunt, Horsfall, and Hanefeld, 2015b, p. 7). Private hospitals in India are drawing medical tourists from Persian Gulf countries, the North, and elsewhere in Asia for high-cost and cutting-edge procedures such as bypass surgeries and transplants (Mullan, 2006, p. 383). Pakistan, China, and the Philippines also serve as enticing hubs for flourishing clandestine organ-transplant tourism (He, 2015, pp. 411–416; also see Martin, 2012, pp. 142–150).13 Tokuda Hospital Sofia (Bulgaria), operated by Japan’s Tokushukai Medical Corporation, draws patients with knee and joint injuries from Persian Gulf states and Libya (Issenberg, 2016, pp. 10–11). Elsewhere, reproductive or fertility tourism for the purpose of assisted conception is increasingly sought after (Whittaker, 2012; Jones and Keith, 2006, p. 252; also see Hudson and Culley, 2015). Unproven, problematic, and perilous stem-cell treatments offer another therapeutic-intervention market that attracts contemporary medical travelers; China and Russia are among the most popular destinations (Martin, 2012, pp. 152–162). Along with renown and sustained operations, faddism and volatility afflict transnational-medical tourism (Lunt, Horsfall, and Hanefeld, 2015a, pp. xvi–xvii). Today, anti-ageing medicine and “active ageing” are ascendant (Hyde and Higgs, 2016, pp. 146–151, 167–174). Will euthanasia tourism be the next hot draw? As Max Hadler (2015, p. 313) points out, “when people cross borders to obtain care, even as willing tourists, it is generally a sign of a real or perceived problem with the local healthcare system.” Northern patients are inspired to seek service abroad by multiple and diverse motivators, including high costs (see Box 1.1) and long waits in their home country (Frenk, et al., 2010, p. 1949; Jones and Keith, 2006, p. 252; Johnson, et al., 2012, p. 29; Smith, et al., 2012, p. 41; Frakt and Carroll, 2018; Crooks, et al., 2013, p. 2). Surgery costs in South Africa, for instance, can be as little as one-third the price charged in London (Renzaho, 2016, p. 186). Transplant and open-heart surgeries as well as knee and hip

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replacements in India can be secured for 10 percent or less of the cost for similar treatment in the USA (Crone, 2008, p. 120; Chen and Wilson, 2013, p. 1753; Turner and Hodges, 2012, p. 10).14

Box 1.1 David’s physical therapy treatment in Cuba Consider David McBain, 47, a Canadian landscaper with a fractured back from an automobile accident. McBain ventured to Cuba for extensive physical therapy three times in 2014. In an interview, McBain reflected on his experience: ‘The physiotherapists and the doctors are extremely knowledgeable and well trained in Cuba and you just can’t beat the price.’ Source: Neuman (2015, p. A7)15

However, advertised costs can be misleading. When transportation, supplies, drugs, and accommodations are factored in, anticipated savings often disappear (Horsfall and Lunt, 2015b, p. 27). In addition, the risks involved in combining long-distance air travel with surgery typically are undisclosed by providing facilities and brokers (Turner, 2012, pp. 260–261). Leigh Turner (2012, p. 267) further points out that one reason that it is possible for international hospitals and clinics to advertise inexpensive medical procedures is that these facilities know there is little chance that they will be held financially accountable if medical travelers experience postoperative complications and require costly follow-up care. Although cost typically is an important consideration among medical tourists, Horsfall and Lunt (2015b, p. 25; also p. 27) contend that “it is not always the key motivator.” Some visitors, for instance, seek “alternative therapies and traditional medicine unavailable in their home country” (Morgan, 2015, p. 97; also Bell, et al., 2015, p. 284). Superior quality of care can be the decisive factor in cross-border health care seeking (see, for instance, Bochaton, 2015b, pp. 278, 283–285; Chanda, 2015, pp. 298–300; Crush, et al., 2015, pp. 327–329; Holliday and Bell, 2015, p. 422). Government initiatives Governments in low-income and middle-income countries increasingly identify medical tourism as an economic-growth engine (Ormond and Mainil, 2015, pp. 154–155; Kanchanachitra, et al., 2012, pp. 63–78; Lee, 2012, pp. 95, 98–99). Thailand, India, Singapore (Turner and Hodges, 2012, p. 11), Taiwan, Malaysia, Korea, Cuba, and South Africa are particularly popular internationally promoted medical-tourist destinations. In Asia, vast medical tourism facilities offer diverse

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and sometimes overlapping clinical specializations (Lunt, Horsfall, and Hanefeld, 2015b, pp. 7, 9). Malaysia showcases cardiology, orthopedics, plastic surgery, and ophthalmology. Thailand advertises dental work, cardiac and cosmetic surgery, cataract removal, and bone-related procedures. Indian websites taut “cardiology and cardiothoracic surgery, joint replacement, orthopedic surgery, gastroenterology, ophthalmology, transplants, and urology” (Whittaker, 2015, p. 117). A multitude of small-scale clinics in South Korea offer niche cosmetic-surgery procedures (Cheung, 2015, pp. 135–136). South Africa’s “surgery and safari” tourism industry is distinguished by dominance of a small number of in-country facilities that target niche markets and by overseas expansion (medical tourism in reverse) on the part of large private-hospital groups (Crush, et al., 2015, pp. 324–325; Crush and Chikanda, 2015, p. 314). Some governments have attracted multinational hospitals and staff who treat medical tourists in special economic zones or clusters (Ormond and Mainil, 2015, p. 155). Providers in places like the Dubai Health Care City build on linkages with recognized institutions like Harvard Medical International in servicing medical tourists (Lunt, Horsfall, and Hanefeld, 2015b, pp. 7, 9; Kronfol, 2015, p. 310). Backed by Chinese and Emirati investors, the Jeju Health Care Town in South Korea caters to Chinese and Emirati-government funded medical tourists (Ormond and Mainil, 2015, pp. 155–156; also see Hodges and Kimball, 2012, p. 121). Even a small country like Rwanda is investing in health-infrastructure initiatives aimed at becoming the center of medical tourism in East Africa; and Ghana is poised to take the lead in West Africa.16 Although less discussed in the literature, countries possessing advanced healthcare systems, including Germany, the United Kingdom, and the USA, also provide transnational-health care. Referrals for specialized care not available in the country of origin figure prominently in South-North and North-North movements (Johnson and Garman, 2015; Johnson, et al., 2012, p. 26). For instance, Malta screens and refers patients for treatment in the UK (Hanefield and Smith, 2015a, p. 106). In Europe, moreover, following adoption of the EU Directive on Patients’ Rights in Cross-Border Health Care in 2011, member states “effectively function as both source and host countries” and intra-regional mobility to secure medical treatment is further facilitated by cooperative agreements (Ormond and Mainil, 2015, pp. 156, 158; Smith, et al., 2012, p. 40; also see Bell, et al., 2015, p. 287). Reported outcomes Valorie Crooks and colleagues conducted one of the few reported studies of medical-tourist interactions with health-care providers abroad. Their interviews with Canadian medical tourists uncovered a “dominant narrative of warm and attentive care abroad .  .  . across .  .  . the range of destinations and procedure types sought.” Indeed, all participants in their study “reported highly positive experiences as medical tourists and none experienced negative health outcomes as a result of treatment abroad” (Crooks, et al., 2015, p. 457). Although the

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respondents’ “overemphasis on patient satisfaction may obscure other important aspects of the treatment experience, such as continuity of care and actual health outcomes” (ibid., p. 458; also Crooks, et al., 2013, pp. 2, 4), such positive treatment impressions constitute a key marker of how patients evaluate relations with providers and can powerfully affect health-promoting behavior (Calnan and Calovski, 2015, pp. 382–384).17 Medical tourism is not a panacea, however; it can “promise hope but deliver despair” (Jones and Keith, 2006, p. 253).18 Even in successful ventures, continuity of care upon return to the country of origin often becomes challenging, complicated, and compromised (Ormond and Mainil, 2015, p. 160; Holliday and Bell, 2015, p. 427; Crone, 2008, p. 120; Turner, 2012, pp. 261–262, 272–273; Cortez, 2012, p. 199). For instance, foreign providers often fail to provide complete documentation of care received (Crooks, et al., 2013, pp. 2, 4) and are disinclined to assume continuing responsibility for the patient’s welfare (Lunt, Horsfall, and Hanefeld, 2015b, p. 9). When medical tourists return, home country health-care facilities and providers must deal with post-operative complications, liability issues, threats to domestic public-health, and “the costs of screening, isolation, and testing for antibiotic-resistant organisms” (Crooks, et al., 2013, pp. 2–5). Enhancing safety and quality of care Responsible medical outsourcing requires that the rapidly expanding health-tourist industry be monitored and regulated. Establishment, in collaboration with the World Health Organization, of medical tourism oversight committees and wide acceptance of patient-focused accrediting agencies would go a long way toward promoting recognized, transparent, and regulated quality care in place of underground treatment (Jones and Keith, 2006, p. 253; Green and King, 2012; Lunt, Horsfall, and Hanefeld, 2015b, p. 11; Ormond, 2015, p. 126; Shaw, 2015; He, 2015, pp. 418–419; Cortez, 2012, p. 197).19 Regional-governance bodies can develop uniform policies that cover cross-border health care (Lunt, Horsfall, and Hanefeld, 2015b, pp. 10–11; Cortez, 2012, p. 198). Further regulatory challenges involve reinforcing professional ethics and redressing social inequities in benefits attributable to private-market dynamics (Ormond, 2015, p. 128; Ormond and Mainil, 2015, p. 160; Chen and Flood, 2013, p. 297). Andrea Whittaker (2015, p. 119) suggests redistributive-financing mechanisms, such as taxing revenues associated with medical tourism and reinvesting the proceeds in the receiving-country’s health system. Patient education, awareness raising, and precaution-responsibility assumption also need to be part of efforts to enhance the safety of travel health (Hodges and Kimball, 2012, p. 132). In support of this effort, Crooks and colleagues (2013, p. 6) maintain that “information about the risks of engaging in medical tourism needs to be effectively transmitted to potential medical tourists.” To address discontinuities in medical documentation and continuity of care among for returning medical tourists, they further argue for “developing a template that destination country physicians complete as a precondition of treatment” (Crooks, et al., 2013, p. 6).

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Factors determining transnational access Wealth is a key contributor to the unequal mobilities that govern transnationalhealth tourism. The most advanced medical centers in the North, for instance, have long welcomed “wealthy patients from low-income and middle-income countries seeking high quality, albeit expensive, medical care” (Frenk, et al., 2010, p. 1949). In addition to high out-of-pocket charges, many foreign patients must be positioned to budget for transportation costs and overstays in nearby hotels (Hughes, 2016). The numbers of wealthy and well-connected transnational-care seekers are growing, particularly persons from the Middle East (Hughes, 2016) and China. Roughly half-a-million citizens of China traveled internationally for medical treatment in 2016 (Wee, 2017, p. B1). The United Kingdom issued approximately 40,000 medical visas to Nigerians in 2012. Other popular care destinations for privileged Southerners and their families include the USA, South Africa,20 Dubai, and India (Renzaho, 2016, p. 186). With increases in life expectancy and the prevalence of chronic conditions in the South, a broader cohort of medical tourists of means are seeking technically skilled and innovative treatments within their own geographical region (Crone, 2008, pp. 117, 120; Hanefeld and Smith, 2015a, p. 106). According to Jonathan Crush and colleagues (2015, p. 327), travel by middle-class and elite patients from elsewhere in Sub-Saharan Africa to South Africa for medical services is “motivated by the unavailability of particular treatments and procedures; quality and safety concerns about facilities at home; increasing costs of medical services in Europe and America; and tightened visa restrictions in the North.” China’s experience offers insights into South-North medical tourism for urgent care among affluent patients. More than four million new cases of cancer are reported in China annually and cancer-survival rates are far lower than in the United States (Wee, 2017, p. B3). Public hospitals are overwhelmed by the number of people requiring treatment: In top public hospitals in the top-tier Chinese cities, lines begin forming just after midnight. Appointments for the best doctors are snapped up before dawn. (Wee, 2017, p. B3) In light of facility and physician shortages and care shortfalls, increasing numbers of wealthy Chinese are opting to pursue critical treatments in the North (see Box 1.2).

Box 1.2 Kefei’s brain tumor treatment in Germany In November 2016, Zhao Xiaoqing, 31, a bridge designer living in Nanjing, traveled with her daughter, Kefei, 5, to Essen University Hospital in Germany for proton-therapy treatment for Kefei’s brain

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Transnational travel as health insurance tumor. “The treatment is available in Shanghai only for children 14 and above. She spent about $140,000, more than half of that borrowed from relatives. Kefei’s tumor shrunk.” Source: Wee (2017, p. B3)

Medical tourism is not restricted to the wealthy, however. In the face of inadequate home country health systems, some families make enormous economic sacrifices in order that a member might pursue desperately needed health care transnationally. In interviews she conducted in Thai hospitals, Whittaker (2015, pp. 118–119) encountered “patients from Vietnam, Myanmar, and Cambodia [who] had borrowed significant amounts of money in order to travel for their health care.” Members of the Somali diaspora community in the UK contribute funds to a common pool that is “used to allow those requiring medical services to travel to Germany, where they access private health-care providers perceived to have better language and medical skills by the Somali community” (Hanefeld and Smith, 2015a, p. 106). In the end, “medical tourism can make the unaffordable affordable, the unavailable available, but still only for those that can raise the funds” (Bell, et al., 2015, pp. 284–285).

Impact of health tourism on population care in southern-treatment countries Medical tourism can be viewed from favorable and unfavorable perspectives. Individual provider and patient well-being can be enhanced at the same time that wider populations suffer as a result. The diverse characteristics of medical tourism produce differential impacts on health systems (Whittaker, 2015, p. 112). Assessments of contributions and drawbacks depend on an array of considerations, including “the type of medical tourism, the individual experiencing it, where treatment is occurring and who is paying” (Lunt, Horsfall, and Hanefeld, 2015a, p. xvii; also Whittaker, 2015, p. 113). The growth in outsourcing health services from North to South (Hancock, 2013, p. 166) can possibly reduce migration incentives among Southern healthcare personnel. In most Southern cases, however, medical tourism “encourages the development of two-tiered health systems within which technologically sophisticated hospitals catering to foreign patients stand beside poorly resourced public hospitals” (Whittaker, 2015, pp. 115–116; also Davies, 2010, pp. 184– 185). Consequently, “international patients obtain access to sophisticated technologies and a high ratio of doctors and nurses to patients, while local citizens remain vulnerable to malnutrition and infectious diseases that could be eradicated with increased investments in public health” (Turner, 2012, p. 270). Cuba, in an exceptional case, has long subsidized its domestic public-health system with income from foreigners paying for cosmetic, cardiac, and ophthalmic services (Lunt, Horsfall, and Hanefeld, 2015b, p. 8; Ormond and Mainil, 2015, p. 161).

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Elsewhere in the South, destination countries are “offering substantial subsidies to the medical tourism industry in an attempt to maintain competitive edge globally” (Chen and Flood, 2013, p. 295). The negative receiving-country effects of medical tourism include “pricing out local patients from technology-driven health care facilities and attracting health care professionals away from facilities serving the local population” (Barros, 2015, p. 76; also Chen and Flood, 2013, p. 291). Clearly, the expansion of transnational-health tourism has exacerbated the internal migration of scarce medical personnel in a number of Southern countries and diverted limited domestic resources from health services needed by most residents (Davies, 2010, pp. 184–185). Instead of engaging in preventive community health and treating local populations with infectious diseases, primary-health-care needs, and chronic conditions, many trained health workers in places like Thailand and India elect to attend to the needs of richer medical tourists (Connell, 2010, pp. 32–33; Whittaker, 2015, pp. 116–118; Chen and Flood, 2013, pp. 289, 292; Lee, 2012, pp. 102–103). In some cases, Southern “doctors have returned from overseas because of opportunities for earning high salaries in the elite private sector hospitals that cater to medical tourists” (Connell, 2010, p. 33; also Mullan, 2006, p. 388; Whittaker, 2015, p. 116; Crone, 2008, p. 117).21 Viewed through the lens of unequal mobilities, both outcomes perpetuate gross disparities in health-care opportunities and quality of services for less-affluent citizens, particularly women, men, and children living in rural and remote areas (Chen and Flood, 2013, pp. 288–290, 293; Hanefeld and Smith, 2015b, p. 39). Fundamentally, the impacts of medical tourism are “the downstream consequence of . . . conscious embrace of health care commoditization over health care rights” (Gaffney, 2016; emphasis in original). The inequitable impact of medical tourism on population-health care in Southern-treatment countries cries out for collaborative global action, revenue-transfer (public-health-system subsidization), and domestic regulation. Possibilities along these lines include an international agreement on equitable health access, taxation of medical tourists, and mandated private-provider contributions to funds devoted to strengthening indigenous health-care systems (Chen and Flood, 2013, p. 297). “Without a robust and carefully tailored regulatory framework that channels any expanded capacity in LMICs’ health-care systems to pre-existing areas of shortages,” Brandon Chen and Colleen Flood (2013, p. 293; also pp. 295, 297) maintain, “the distribution of these newfound health resources may continue to skew in favour of medical tourists, and leave the emaciated supply of health services vis-à-vis local residents, particularly the poor, largely unimproved” (also see Lee, 2012, pp. 104–107).

Medical tourism and biosecurity The biosecurity implications specifically associated with medical tourism merit attention in a work on transnational mobility and global health. It is important to recognize, first, that “the specific environment within which medical tourism

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occurs is likely to offer a far higher likelihood of exposure to pathogens and subsequent risks of infection than other forms of tourism” (Hall, 2015, p. 199; also Chen and Wilson, 2013). Hodges and Kimball (2012, p. 117; also p. 121) remind us that “patients traveling for medical care are exposed to a host of pathogens each step of their journeys, from the taxi to the airport to the hotel they stay for their recovery.” Hospitalization increases the risk of nosocomial (health-care-originating) infections (Chen and Wilson, 2013, p. 1756; Hodges and Kimball, 2012, p. 122). Antibioticresistant strains of mycobacterium abscessus have been traced to cosmetic-surgery tourism (Chen and Wilson, 2013, p. 1756; Hall, 2015, pp. 196–198; also see Hodges and Kimball, 2012, p. 115). Risks for nosocomial infections are highest for patients in intensive-care units and those receiving transplants (Hodges and Kimball, 2012, pp. 122, 124–125; Crooks, et al., 2013, p. 2). The spread of disease via international travel presents a growing challenge.22 Unquestionably, “the churn of patients and their companions cycling in and out of international medical facilities and back to their home communities establishes a highly efficient pathogenic breeding and distribution system” (Hodges and Kimball, 2012, p. 131). Confinement during air travel presents conducive opportunities for disease transmission (ibid., pp. 118–119). Of particular concern, transnational medical tourism facilitates the mobility of antibiotic-resistant infections; that is, travelers move “bacteria and resistance genes globally” (Chen and Wilson, 2013, p. 1756; also Hodges and Kimball, 2012, p. 115). In addition, Michael Hall (2015, p. 196) foresees that “increasing air connectivity with respect to both the frequency and number of air passenger services between continental regions will lead to a corresponding increase in the number and frequency of vector and species introductions” at the same time that climate change enhances prospects that hitchhiking vectors will be successfully established in the new environment. A combination of daunting governance and regulatory challenges makes the management of escalating “medical tourism-related biological exchange” increasingly difficult (ibid., pp. 194–196).23 After detailing the challenging conditions, Hall (ibid., p. 199; also p. 200) suggests that biosecurity practices be “specifically developed for medical tourists upon both exit and entry into a country as well as appropriate profiling, risk management, and surveillance and monitoring strategies.” A number of international networks, including WHO’s Global Outbreak Alert and Response Network (GOARN), GeoSentinel, ProMED-mail (Program for Monitoring Emerging Diseases), the Global Public Health Intelligence Network (GPHIN), and the automated event-report-based HealthMap, now engage in disease outbreak surveillance and reporting (McCracken and Phillips, 2017, pp. 51, 362). All biosecurity initiatives face technical challenges and political/ economic resistance (Hodges and Kimball, 2012, pp. 128–129, 131–132).

Other forms of mobility: transnational-corporate health-care systems and E-health for the global south Mobility indicators are embedded in multiple dimensions of global health (WaltonRoberts, 2015, p. 239). In addition to travelers’ health and health tourism, the rise

Boxes vii 6.5 The quarantine of Kaci Hickox upon return from five weeks treating Ebola patients in Sierra Leone 7.1 Rural-urban migration in Bangladesh following Cyclone Aila in 2009 8.1 Tewolde Habtemicael’s circular-migration story 8.2 Upstream armed-conflict epidemiology

180 194 219 224

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with physicians located in the North. Contemporary supportive transnational physician-to-physician remote interactions involve “telepathology, telesurgery, emergency, and trauma medicine and teleradiology” (Hanefeld and Smith, 2015b, pp. 38–39; also see Crisp, 2016, p. 218). In spring 2017, for instance, the Swinfen Charitable Trust operated a network of 672 clinicians available by email for consultations at 349 hospitals in 78 countries and post-conflict places.26 Still to be developed are telemedicine conversations among Northern and Southern physicians that address chronic and unusual health challenges faced by migrants in residence abroad.27

Conclusion: unequal mobilities and travelers’ health Health and mobility cover the gamut from expanded treatment opportunities to desperation grasping. The first chapter of Transnational Mobility and Global Health focused on the opportunity angle. Whether the subject of concern be travelers’ health, medical tourism, transnational-corporate involvement, or E-health, networking plays a critical role. The individual consumer bears the bulk of the burden of “navigating this world of globalized medicine” (Issenberg, 2016, p. 34) and networking is demanding, stratified, and facilitated by transnational social capital – a resource closely associated with privilege and social class. As Steffen Mau and Jan Mewes (2009, p. 170) assert, “Highly educated individuals and persons in higher occupational positions . . . tend to be more spatially mobile, which increases the chances of making more contacts with an increasing number of people.” Clearly, mobile people are assuming greater personal responsibility for transnational medical-care decisions. The extent to which patients with no medical training successfully navigate the network-information and internet overload of competing claims and commercial interests is contextually determined (Bell, et al., 2015, pp. 284–285). The British Columbia health and safety experts consulted in the Crooks study “generally felt medical tourists were uninformed about risks they may face abroad, as well as factors they should consider when selecting a facility.” For many aspiring medical mobiles, these challenges are compounded by “misleading or incomplete information on websites, [and] difficulties in obtaining information about success rates and the quality of care in destination facilities” (Crooks, et al., 2013, pp. 4–6, 2). This chapter has shown that, in most cases, transnational medical travels offer a striking illustration of global disparities in health care. The next chapter also is concerned with unequal care, but abruptly shifts the health and mobility focus from privilege and possibility to desperation and despair.

Notes 1 This conception of transnational care is meant to encompass crossing adjoining borders as well as journeys of longer distance (see Connell, 2015, pp. 18, 20, 22–23). 2 Domestic movements from small towns and rural areas to cities for medical care, while extensive (Connell, 2015, p. 17), fall outside the transnational focus of this work.

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3 Considerable medical tourism involves diaspora populations returning to places of origin (Connell, 2015, pp. 16, 20–21). This dimension is treated in-depth in Chapter 4. 4 However, nearly 700,000 fewer foreigners visited the United States in the first quarter of 2017 compared with 2016 (Glusac, 2017). 5 For instance, see “International Travel Center.” www.umt.edu/curry-health-center/ medical/Travelers-Health.php. 6 For especially risky destinations, see Noack (2015). 7 Analysis based on data provided in Table 1 of Leder, et al. (2013, p. 458). 8 On child-health tourism for elective treatment, diagnostic procedures, alternative therapies, and services unavailable in their home country, see Hamlyn-Williams, Lakhanpaul, and Manikam (2015). 9 Based on this definition (also see Turner and Hodges, 2012, pp. 6–7), I use transnational travel for medical procedures and health and wellness practices interchangeably. Although not all transnational medical- health-care seekers engage in tourism, and some are forced to seek external help due to the unavailability of domestic services, the term “medical tourist” is widely understood to refer to those who travel abroad in search of health care for a host of reasons – including thermal healing waters (Smith, Puczko, and Sziva, 2015), dental (Chanda, 2015) and ocular procedures, alternative therapies, and wellness practices. 10 Glenn Cohen (2015, p. 350; also see pp. 351–353) refers to traveling abroad for services that are illegal in one’s home country (such as for abortion, reproductive technologies, and assisted suicide) as “circumvention tourism.” 11 For Thailand, the main ingredients in successful promotion of health tourism are “the quality of medical services, low cost of obtaining services of similar/acceptable quality, price certainty through fixed package prices offered by medical facilities, the welldeveloped tourism industry” (Supakankunti, 2014, p. 680; also see p. 683; also Noree, 2015). 12 In some cases, transnationally mobile providers engage in face-to-face consultations with prospective patients before surgery – for instance, Korean cosmetic surgeons who travel to China (Cheung, 2015, p. 137). Several hospitals in Singapore operate international-referral offices in Southeast Asia and beyond (Gan and Frederick, 2015, p. 143). 13 On the long-term health risks that confront impoverished persons who sell kidneys to medical tourists, see Turner (2012, p. 271). 14 “Liver Transplant in India.” www.indicure.com.ng/organ_transplant/liver_transplant_ in_india.htm; accessed 23 July 2017. 15 For earlier evidence regarding the treatment of medical tourists in Cuba, view Michael Moore’s documentary Sicko. 16 Email of 21 October 2016 from the Corporate Council on Africa titled “Unlocking Africa’s Health Tourism Sector.” 17 For more nuanced pictures focused on outcomes that take into consideration types of procedures accessed abroad, see Lunt and Horsfall (2015) and Chen and Wilson (2013, p. 1756). 18 In addition, the risk of contracting infectious diseases is high in many low-cost travelhealth destinations. Ironically, this risk is exacerbated when “governments’ focus on medical tourism results in fewer resources or medical personnel to treat local populations” (Hodges and Kimball, 2012, p. 120). 19 The Joint Commission International (JCI) of the Joint Commission on the Accreditation of Health Care Organizations had certified nearly 1,000 institutions in multiple Southern countries by July 2017 (www.jointcommissioninternational.org/about-jci/ jci-accredited-organizations/). However, “it is unclear whether JCI sets a sufficiently robust standard when evaluating international medical facilities” (Turner, 2012,

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20 21 22

23 24

25 26 27

Transnational travel as health insurance p. 273; also Crooks, et al., 2013, p. 2) and JCI does not assess outcomes (Chen and Wilson, 2013, p. 1753). For a list of organizations focused on health care quality and safety internationally, see Chen and Wilson (2013, Table 2, p. 1755). On the vast number of annual medical tourists in South Africa from elsewhere in Sub-Saharan Africa, see Renzaho (2016, p. 186; Crush, et al., 2015, p. 327; Crush and Chikanda, 2015, pp. 313, 319). Singapore and Malaysia, however, have actively pursued foreign doctors (Kanchanachitra, et al., 2012, p. 79). SARS provided the contemporary wake-up message in this connection: “Human travel was the key to the rapid global spread of severe acute respiratory syndrome (SARS), which spanned more than two dozen countries and resulted in 774 deaths in 2003” (Hodges and Kimball, 2012, p. 117). On the limitations of the WHO’s International Health Regulations (IHR), see Hodges and Kimball (2012, pp. 130–132). In Asia, multinational medical corporations, such as the Fortis Parkway group, are investing in private-hospital chains (Whittaker, 2015, p. 120). In Africa, in contrast, private foreign investment in the health sector, a direction likely to divert “much needed resources to curative and high-end procedures” and to exacerbate health inequality, has not yet taken off (Renzaho, 2016, p. 187; also p. 189). For an insightful discussion of ethical concerns surrounding medical-tourism facilitators, see Snyder, et al. (2012). “Swinfen Telemedicine Newsletter.” www.swinfencharitabletrust.org/publications/ newsletters/Swinfen_A5_12pp_Newsletter_Spring2017.pdf; accessed 22 July 2017. It is noteworthy in this connection that a survey of practices in hospital cardiology departments in several European countries found that doctors “‘rarely’ made contact with the patients’ primary care doctors in their country of residence” (Hodges and Kimball, 2012, p. 132).

References Angell, Sonia Y.; and Cetron, Martin S. 2005. “Health Disparities among Travelers Visiting Friends and Relatives Abroad.” Annals of Internal Medicine 142, No. 1 (4 January): 67–71. Barros, Pedro P. 2015. “Health Systems and Medical Tourism.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 71–81. Bell, David; Holliday, Ruth; Ormond, Meghann; and Mainil, Tomas. 2015. “Transnational Health Care, Cross-Border Perspectives.” Social Science & Medicine 124:284–289. Bochaton, Audrey. 2015a. “Cross-Border Mobility and Social Networks: Laotians Seeking Medical Treatment along the Thai Border.” Social Science & Medicine 124:364–373. Bochaton, Audrey. 2015b. “International Medical Travel Developments within Thailand and Southeast Asia.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 278–287. Brody, Jane E. 2016. “Staying Healthy While Travelling the Globe.” New York Times, 22 February. Bustamante, Arturo V. 2015. “United States (US)-Mexico Bi-National Insurance Efforts and the Prospective Impacts of Healthcare Reforms in the US and Mexico.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 247–257.

Transnational travel as health insurance

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Calnan, Michael; and Calovski, Vid. 2015. “Medical Tourism and Trust: Towards an Agenda for Research.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 379–390. Chanda, Rupa. 2015. “Medical Tourism and Outward FDI in Health Services: India in South Asia.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 296–306. Chen, Lin H.; and Wilson, Mary E. 2013. “The Globalization of Healthcare: Implications of Medical Tourism for the Infectious Disease Clinician.” Emerging Infections 57:1752–1758. Chen, Y.Y. Brandon; and Flood, Colleen M. 2013. “Medical Tourism’s Impact on Health Care Equity and Access in Low-and Middle-Income Countries: Making the Case for Regulation.” Journal of Law, Medicine and Ethics 41 (1):286–300. Cheung, Olive N.Y. 2015. “A Review of Small-Scale Niche Treatment Providers.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 133–140. Cohen, I. Glenn. 2015. “Medical Tourism for Services Illegal in Patients’ Home Country.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 350–359. Connell, John. 2010. Migration and the Globalisation of Health Care: The Health Worker Exodus? Cheltenham, UK: Edward Elgar. Connell, John. 2015. “Medical Tourism: Concepts and Definitions.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 16–24. Cortez, Nathan. 2012. “Into the Void: The Legal Ambiguities of an Unregulated Medical Tourism Market.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 187–206. Crisp, Nigel. 2016. One World Health: An Overview of Global Health. Boca Raton, FL: CRC Press. Crone, Robert K. 2008. “Flat Medicine? Exploring Trends in the Globalization of Health Care.” Academic Medicine 83, No. 2 (February):117–121. Crooks, Valorie A.; Casey, Victoria; Whitmore, Rebecca; Johnston, Rory; and Snyder, Jeremy. 2015. “‘They Go the Extra Mile, the Extra Ten Miles . . .’: Examining Canadian Medical Tourists’ Interactions with Health Care Workers Abroad.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 451–460. Crooks, Valorie A.; Turner, Leigh; Cohen, I. Glenn; Bristeir, Janet; Snyder, Jeremy; Casey, Victoria; and Whitmore, Rebecca. 2013. “Ethical and Legal Implications of the Risks of Medical Tourism for Patients: A Qualitative Study of Canadian Health and Safety Representatives’ Perspectives.” BMJ Open 3:e002302. Crush, Jonathan; and Chikanda, Abel. 2015. “South-South Medical Tourism and the Quest for Health in Southern Africa.” Social Science & Medicine 124:313–320. Crush, Jonathan; Chikanda, Abel; Sanders, David; and Maswikwa, Belinda. 2015. “The Rise of Medical Tourism to South Africa.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 323–331. Davies, Sara. 2010. Global Politics of Health. Cambridge, UK: Polity Press. Frakt, Austin; and Carroll, Aaron E. 2018. “Where U.S. Health Care Stands Out: Price.” New York Times, 2 January, pp. B1–B2.

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Frenk, Julio; Chen, Lincoln; Bhutta, Zulfiqar A.; Cohen, Jordan; Crisp, Nigel; Evans, Timothy; Fineberg, Harvey; Garcia, Patricia; Ke, Yang; Kelley, Patrick; Kistnasamy, Barry; Meleis, Afaf; Naylor, David; Pablos-Mendez, Ariel; Reddy, Srinath; Scrimshaw, Susan; Sepulveda, Jaime; Serwadda, David; and Zurayk, Huda. 2010. “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World.” Lancet 376 (4 December):1923–1958. Gaffney, Adam. 2016. “Need Surgery, Will Travel.” New Republic, 13 January. Gan, Lydia L.; and Frederick, James R. 2015. “Regional Differences: Scope and Trust among Medical Tourism Facilitators.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 141–153. Glusac, Elaine. 2017. “Flow of Tourists to U.S. Declined in First Quarter.” New York Times, 20 September, p. A18. Green, Stephen T.; and King, Hannah. 2012. “Independent Health Care Accreditation: Medical Tourism and Other International Aspects.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 230–250. Hadler, Max W. 2015. “Migration and Patient Mobility in Latin America.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 313–332. Hall, C. Michael. 2015. “The Coming Perfect Storm: Medical Tourism as a Biosecurity Issue.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 193–204. Hamlyn-Williams, Charlotte; Lakhanpaul, Monica; and Manikam, Logan. 2015. “Child Medical Tourism: A New Phenomenon.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 360–369. Hancock, John. 2013. “Global Trade and Health Diplomacy: Maximizing Cooperation and Minimizing Conflict through Coherent International Rules.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 155–171. Hanefeld, Johanna; Lunt, Neil; Smith, Richard; and Horsfall, Daniel. 2015. “Why Do Medical Tourists Travel to Where They Do? The Role of Networks in Determining Medical Travel.” Social Science & Medicine 124:356–363. Hanefeld, Johanna; and Smith, Richard. 2015a. “Financing Mechanisms.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 104–111. Hanefeld, Johanna; and Smith, Richard. 2015b. “Globalization and Trade in Health Services.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 37–44. He, Alex J. 2015. “Transplantation Tourism in Asia: Snapshot, Consequences and the Imperative for Policy Changes.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 411–420. Hodges, Jill R.; and Kimball, Ann Marie. 2012. “Unseen Travelers: Medical Tourism and the Spread of Infectious Disease.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 111–137.

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Holliday, Ruth; and Bell, David. 2015. “Cosmetic Surgery Tourism.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 421–430. Horsfall, Daniel; and Lunt, Neil. 2015a. “Medical Tourism and the Internet.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 174–183. Horsfall, Daniel; and Lunt, Neil. 2015b. “Medical Tourism by Numbers.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 25–36. Hudson, Nicky; and Culley, Lorraine. 2015. “Cross-Border Reproductive Travel.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 441–450. Hughes, Carroll J. 2016. “Hospitals Nearby, Builders Show Good Bedside Manners.” New York Times, 21 December, p. B8. Hyde, Martin; and Higgs, Paul. 2016. Ageing and Globalisation. Bristol, UK: Polity Press. Issenberg, Sasha. 2016. Outpatients: The Astonishing New World of Medical Tourism. New York: Columbia Global Reports. Johnson, Tricia J.; and Garman, Andrew N. 2015. “Travelling for Value: Global Drivers of Change in the Tertiary and Quaternary Markets.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 57–67. Johnson, Tricia J.; Garman, Andrew N.; Hohmann, Samuel F.; Meurer, Steven; and Allen, Molly. 2012. “The United States: Destination and Departure Point.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 19–36. Jones, C.A.; and Keith, L.G. 2006. “Medical Tourism and Reproductive Outsourcing: The Dawning of a New Paradigm for Healthcare.” International Journal of Fertility 51 (6):251–255. Kanchanachitra, Churnrurtai; Pachanee, Cha-aim; Dayrit, Manuel M.; and Tangcharoensathien, Viroj. 2012. “Medical Tourism in Southeast Asia: Opportunities and Challenges.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 56–86. Kronfol, Nabil M. 2015. “Medical Tourism Development within the Middle East.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 307–312. Leder, Karin; Torresi, Joseph; Libman, Michael D.; Cramer, Jakob P.; Castelli, Francesco; Schlagenhauf, Patricia; Wilder-Smith, Annelies; Wilson, Mary E.; Keystone, Jay S.; Schwartz, Eli; Barnett, Elizabeth D.; von Sonnenburg, Frank; Brownstein, John S.; Cheng, Allen C.; Sotir, Mark J.; Esposito, Douglas H.; and Freedman, David O. 2013. “GeoSentinel Surveillance of Illness in Returned Travellers, 2007–2011.” Annals of Internal Medicine 158:456–468. Lee, Courtney A. 2012. “Socialized Medicine Meets Private Industry: Medical Tourism in Costa Rica.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 87–108. Legido-Quigley, Helena; and McKee, Martin. 2015. “European Retirement Migration: Access to Health Care and Policy Implications.” In Handbook on Medical Tourism and

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Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 258–267. Lunt, Neil; and Horsfall, Daniel. 2015. “Outcomes and Medical Tourism.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 461–471. Lunt, Neil; Horsfall, Daniel; and Hanefeld, Johanna. 2015a. “Introduction: The Emergence and Significance of Medical Tourism and Patient Mobility.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. xiv–xvii. Lunt, Neil; Horsfall, Daniel; and Hanefeld, Johanna. 2015b. “The Shaping of Contemporary Medical Tourism and Patient Mobility.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 3–15. Martin, Dominique. 2012. “Perilous Voyages: Travel Abroad for Organ Transplants and Stem Cell Treatments.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 138–166. Mau, Steffen; and Mewes, Jan. 2009. “Class Divides within Transnationalisation: The German Population and Its Cross-Border Practices.” In Mobilities and Inequality, edited by Timo Ohnmacht, Hanja Maksim, and Manfred M. Bergman. Burlington, VT: Ashgate. Pp. 165–185. Mavroudi, Elizabeth; and Nagel, Caroline. 2016. Global Migration: Patterns, Processes, and Politics. London: Routledge. McCracken, Kevin; and Phillips, David R. 2017. Global Health: An Introduction to Current and Future Trends. London: Routledge. Morgan, David. 2015. “Accounting for Trade in Healthcare.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 92–103. Mullan, Fitzhugh. 2006. “Doctors for the World: Indian Physician Emigration.” Health Affairs 25 (2):380–393. Neuman, William. 2015. “U.S. Tourists May Feel Cuba’s Pull for Health.” New York Times, 18 February, pp. A1, A7. Noack, Rick. 2015. “Map: Whatever You Do, Don’t Get Sick in These Countries.” Washington Post, 20 February. Noree, Thinnakorn. 2015. “Medical Tourism: A Case Study of Thailand.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 268–277. Ormond, Meghann. 2015. “What’s Where? Why There? And Why Care? A Geography of Responsibility in Medical Tourism.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 123–130. Ormond, Meghann; and Mainil, Tomas. 2015. “Government and Governance Strategies in Medical Tourism.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 154–163. Renzaho, Andre M.N. 2016. “Health, Social and Economic Impact of Voluntary Migration.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 123–203.

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Shaw, Charles D. 2015. “Hospital Accreditation and Medical Tourism.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 370–378. Smith, Melanie; Puczko, Laszlo; and Sziva, Ivett. 2015. “Putting the Thermal Back into Medical Tourism.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 393–402. Smith, Richard D.; Legido-Quigley, Helena; Lunt, Neil; and Horsfall, Daniel. 2012. “Medical Tourism the European Way.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 37–55. Snyder, Jeremy; Crooks, Valorie A.; Wright, Alexandra; and Johnson, Rory. 2012. “Medical Tourism Facilitators: Ethical Concerns about Roles and Responsibilities.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 279–295. Supakankunti, Siripen. 2014. “Medical Tourism in Thailand.” In Routledge Handbook of Global Public Health in Asia, edited by Sian M. Griffiths, Jin Ling Tang, and Eng Kiong Yeoh. London: Routledge. Pp. 669–687. Turner, Leigh. 2012. “Medical Travel and the Global Health Services Marketplace: Identifying Risks to Patients, Public Health, and Health Systems.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 253–278. Turner, Leigh; and Hodges, Jill R. 2012. “Introduction: Health Care Goes Global.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 1–16. Walton-Roberts, Margaret. 2015. “Migration: The Mobility of Patients and Health Professionals.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 238–246. Wee, Sui-lee. 2017. “Life-or-Death Medical Tourism.” New York Times, 30 May, pp. B1, B3. Weed, Julie. 2018. “Study Abroad for People Who No Longer Have to Worry about Grades.” New York Times, 10 April, p. B2. Whiting, Ed. 2017. “‘Antibiotic Apocalypse’: Doctors Sound Alarm over Drug Resistance.” Observer, 8 October. Whittaker, Andrea. 2012. “Cross-Border Assisted Reproductive Care: Global Quests for a Child.” In Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services, edited by Jill R. Hodges, Leigh Turner, and Ann Marie Kimball. Santa Barbara, CA: Praeger. Pp. 167–183. Whittaker, Andrea. 2015. “The Implications of Medical Travel upon Equity in Lower-and Middle-Income Countries.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 112–122.

2

Health challenges for refugees and conflict-induced migrants Transit conditions, camps, and settlements

Armed conflict is gaining recognition as a daunting public-health issue (McCracken and Phillips, 2017, p. 317; Ottersen, 2014, pp. 651–659). UNHCR’s 2016 Global Trends Report alerts us that “more people are on the run than ever before in recorded history” (Sengupta, 2016). The vast majority of the victims of contemporary armed conflicts are civilians (Ottersen, 2014, p. 651). Further, most conflict-displaced migrants do not leave the Global South (Mavroudi and Nagel, 2016, p. 137). Working at the interface of political determinants with migration and health, Chapter 2 explores the upstream contributors to Southern conflicts and treats the initial stages of conflict-induced migration. The collateral health consequences of armed conflict and the physical- and mental-health impacts of involuntary internal displacement (along with forced immobility) also receive treatment. This chapter devotes specific attention to refugees, asylum seekers, and “people of concern” to UNHCR.1 Physical- and mental-health conditions in camps and settlements are explored. Chapter 2’s treatment of health challenges for refugees and conflict-induced migrants incorporates analysis of the roles and responsibilities of U.N. peacekeeping forces, UNHCR, UNDP, the International Organization for Migration (IOM), host governments, the International Committee of the Red Cross, Médecins Sans Frontières (MSF), and other NGOs. Also included in this chapter’s discussion are health and safety issues associated with repatriation. Chapter 2 concludes by exploring prospects that health appeals can serve as a bridge to peace.

Upstream contributors to southern conflicts Both upstream institutional forces and individual assessments play a compelling part in refugee formation. In the analysis of conflict-induced migration, three levels of consideration are required: transnational political and economic interactions, intervening national conditions and events, and personal/family deliberations. The interaction of national and transnational economic and political forces shapes and conditions internal conditions and policy developments that catalyze population dislocations and migration decisions.

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The roots of many contemporary migrant-generating conflicts can be traced to North-South political dynamics (Samers and Collyer, 2017, p. 3; GarciaZamora, 2017, p. 591). By shaping the political-economic triggers of armed conflict and persecution, transnational institutional conditions both constrain and facilitate population movement. Key features of the global economy, particularly unequal terms of international trade and finance, penetration by multinational corporations, and the hegemonic influence of certain multinational gatekeepers, undermine healthy lifestyles (Jacobs and Richtel, 2017) and foreclose sustainable development in much of the Global South. Commitment to neo-liberal principles under the Washington Consensus sustained Northern exploitation of Southern economies, a process expanded by the post-Washington Consensus to involve the imposition of sweeping conditionalities under the umbrella of “good governance” (Fine and Saad-Filho, 2014). Global and domestic economic inequities and resulting hardships, in turn, prod threatened regimes to stifle opposition through political persecution, human-rights violations, and the application of systematic violence (Toole, 2006, p. 190; Ottersen, 2014). Oppressive regime actions and reactions help to ignite spiraling civil strife. Venezuela provides one contemporary case in point (see Box 2.1; Benzaquen, 2017). Multinational institutions, meanwhile, have proven ineffective in mitigating the volatile underlying mix of domestic disparities and “external disruptors” that catalyze armed conflicts in the South (Ottersen, 2014, p. 653; Koehn, 1991).

Box 2.1 Venezuela’s Cruz Verde responds to protest injuries A teenage boy lay on the ground after a clash with the police. “Medico, medico!” a young man screamed through the thick fog of tear gas at a protest in Caracas, Venezuela. The medics he was calling for, known as the Cruz Verde or Green Cross, have become a regular fixture at violent clashes between opposition protesters and government forces. At least 90 people have died since the demonstrations began in April. . . . Video showed Green Cross volunteers crowding around the injured teenager, Neomar Lander, 17, and carrying him out of the worst of the fighting. Mr. Lander later died. But group organizers say they treat dozens of patients daily, and believe that the first aid they deliver has been crucial in saving lives. The Venezuelan economy’s near-collapse has devastated medical facilities and supply lines, and limited state-run emergency care at demonstrations, according to the group. . . . Many of the volunteers are students in their 20s. Dozens of qualified doctors have also joined their ranks, which number around 200 in Caracas. They have similar affiliated groups that attend protests around the country.

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Health challenges for refugees But getting in the middle of the protests is dangerous, and several Green Cross medics have been injured. At least one was killed while volunteering. Source: extracts from reporting by Megan Specia (2017)

The rise of terrorist groups further exacerbates the explosive nature of living conditions for vulnerable populations. Across the globe, Kevin McCracken and David Phillips (2017, p. 323) note that “a particularly dark side of violent conflict and global health is the loss of life and injuries sustained in terrorist attacks.” In Globalization and Migration, Elliot Dickenson (2017, p. 3) writes, The nexus between migration and terrorism again reared its ugly head in Paris on the cool fall evening of Friday, November 13, 2015, when at least 130 people were killed in six coordinated attacks carried out by Islamic State militants. Although no place is entirely safe, “by far the greatest burden of terrorism-related mortality and morbidity and ongoing threat to personal and public well-being are borne by developing nations” (McCracken and Phillips, 2017, pp. 323–324). In the Global South, an externally armed and supported regime with a weak and divided base of support among the local population frequently proves unable to eliminate terrorist actions in spite of stepped-up repression. The end result is widespread, costly, and protracted armed confrontations. Further, the impetus for social transformation and the reconstruction of political legitimacy is diminished by the need to divert scarce national resources into military repression. With specific reference to out-migration from Ethiopia, Solomon Gofie (2016) maintains that transnational support for a regime that deprives the populace of “dignity, freedom [of expression and association] and life under the rule of law” (p. 15), denies popular control over relations with the state, and ruthlessly treats opponents, lies at the root of contemporary emigration trends. The emergence of terrorist groups in the Horn of Africa provides a convenient pretext for Northern cooptation of regional security forces that are trained and equipped to forestall emigration to Europe and beyond (p. 15) at the same time that external actors overlook the basic “domestic political oppression and economic deprivation” (p. 11) that propels out-migration.2 According to Solomon (p. 3; also p. 16), the real reason that mass numbers of people have fled from Ethiopia and Eritrea lies in the antagonistic and tense relations with the state in which people feel a profound sense of fear, fragmentation, and disunity. The view that people migrate from the one part of the world to the other where the living condition is much better is an oversimplification of the reality of emigration. People are migrating to the part of the world where the would-be host communities are perceived to be peaceful, and are in harmonious relation with

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that state, where the rule of law is an organizing principle of the national political community. At the individual and family decision-making level, involuntary migration is a response to perceived stress in satisfying basic survival needs. That some people opt to move and others do not is a complex phenomenon related to personal/ family background and orientations, exposure to harrowing incidents, reactions to events and policy directions, and the opportunity and capacity to escape (see Koehn, 1991, Chapter 1). Particularly useful means for safe exit from one’s country of origin are money, access to reliable sources of information, links to transnational contacts and networks, and proximity to a porous border. Conflict-inspired migration presents serious challenges for population health, provider response, and health systems (Pottie, Hui, and Schneider, 2016, p. 299). In Andrew Price-Smith’s terminology (2009, pp. 160–163), war serves as a “disease amplifier.” Others perceive that health-system crises that retard the ability of women to function as peace negotiators contribute to the initiation and prolongation of conflict situations (Davies, 2010, p. 124). The following sections explore health impacts from the initial stages of armed conflict through immediate reception places for dislocated populations.

Initial stages of conflict-induced migration In spite of the protections afforded to non-combatants under the Geneva Conventions of 1949, civilians bear the brunt of contemporary armed conflicts (Kaldor, 2012, pp. 9, 171) that profoundly and often directly affect the health status of dislocated as well as immobile populations (Sidel and Levy, 2008, pp. 49–50). During the protracted civil war that engulfed Syria, an estimated 11.5 percent of the country’s population had been killed or injured by 2015 (McCracken and Phillips, 2017, p. 318) – an unfathomable statistic (also see Specia, 2018). The most extreme ill-health manifestations are deaths associated with genocidal and ethnic cleansing impulses. Populations in Cambodia, Rwanda, South Sudan, the Democratic Republic of Congo (DRC),3 and Myanmar4 have suffered from the ethnic-cleansing malady (Toole, 2006, p. 193; Ives, 2016). Civilian targeting Increasingly, military operations by all parties to an armed conflict have intentionally targeted civilians. In what Mary Kaldor (2010, p. 9; also p. 104) calls the “new warfare”, the aim is to control the population by getting rid of everyone of a different identity (and indeed of a different opinion) and by instilling terror. . . . This often involves population expulsion through various means such as mass killing and forcible resettlement, as well as a range of political, psychological, and economic techniques of intimidation.

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In Mozambique, for instance, “antigovernment forces killed approximately 100,000 civilians in 1986 and 1987” (Toole, 2006, p. 193; also Tavernise, 2016). The Gaza conflict of 2014 left 2,251 Palestinians dead and another 11,203 injured, many of whom are permanently disabled (McCracken and Phillips, 2017, p. 318). Iraqi, U.S.-led coalition, and Islamic State forces killed an estimated 9,000 to 11,000 civilians in fighting over Mosul between October 2016 and July 2017 (George, et al., 2017). In the Northern Nigeria state of Borno, Boko Haram militants “now favour destructive raids”; at least 85 civilians died in 2016 when they “attacked the village of Dalori, laying fires, detonating bombs, and shooting civilians” (Burki, 2016). At the same time that those thought to sympathize with the Government are subject to attack by militants, thousands of people in areas once occupied by Boko Haram, suspect in the eyes of the Nigerian armed forces, are arbitrarily incarcerated and killed (Burki, 2016). In 2017 alone, “more than 10,000 children were killed or maimed in armed conflicts” according to a UN report (Sugiyama, 2018). Civilian survivors trapped in cross-fire and used as human shields suffer severe physical and psychological harm (see Box 2.2). Human-rights abuses, including arbitrary arrests, forced child recruitment, beheadings, torture, sexual violence, and forced displacement, inflict irreparable physical damage and psychological trauma (Toole, 2006, pp. 194–195; McMichael, Barnett, and McMichael, 2012, p. 649; Sengupta and Saad, 2017; McCracken and Phillips, 2017, pp. 319–321; Fink, 2017). In an exceptionally compelling case, Yazidi women who manage to escape captivity, rape, and torture by Islamic State extremists “are left with deep psychological scars” and residence in a place where helping psychiatrists, physicians, counselors, and other health workers are challenged by recurring manifestations of the victims’ “unimaginable trauma” (Rising, 2017; Porter, 2018).

Box 2.2 Civilian casualties in Mosul, Iraq, 2017 In Mosul, “civilians have long been caught between Islamic State snipers, who target those trying to leave, and heavy bombardment from Iraqi and coalition forces.” According to Bruno Geddo, head of UNHCR’s operations in Iraq, “they have seen unspeakable violence.” Exit is perilous5 and many of those who remained in Islamic State-controlled areas of the city were injured, malnourished, and traumatized. Source: Specia and Boshnaq (2017)

Organized violence, desecration of culturally valued landmarks, provoking hatred, and the deliberate use of rape against opponents or populations targeted for forced displacement occur as war strategies or as part of a calculated effort to control valuable land and natural resources by “maximizing misery”6 through “extreme and conspicuous atrocity” (Kaldor, 2012, pp. 104–105). Multiple forms of gender-based violence produce negative health consequences and

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generate refugee flows (Penttinen and Kynsilehto, 2017, p. 115). Gender-based violence – particularly widespread in the Democratic Republic of Congo (see Gettleman, 2017, pp. 222–223), South Sudan, Rwanda, Northeast Nigeria, Iraq, and Syria (McCracken and Phillips, 2017, p. 331; Cumming-Bruce, 2017c; Ottersen, 2014, pp. 651–652; Price-Smith, 2009, pp. 182, 184–185; Searcey, 2017a) – also exacerbates the risk of sexually transmitted infections (Toole, 2006, p. 194; Rajabali, et al., 2009, pp. 611–612). Incidental damage The incidental damage associated with armed conflict and the remnants of war also often negatively affects population health (McCracken and Phillips, 2017, pp. 321–323; Davies, 2010, p. 123). In January 2017, for instance, deliberate targeting of Damascus’ water-supply infrastructure resulted in a health-impairing water crisis (Hubbard, 2017). In the throes of armed conflict, moreover, food needed for people’s sustenance is destroyed, diverted, and looted (Toole, 2006, pp. 195–196). The resulting chronic and acute malnutrition increases risks of morbidity and mortality (Price-Smith, 2009, p. 162; Davies, 2010, p. 123).7 At the same time that injuries incurred during armed conflict increase the need for blood transfusions, safe procedures are compromised both in war zones and in overwhelmed host countries (Rajabali, et al., 2009, p. 613). The continuing war in Syria has driven down the average life expectancy for males by six years and for females by five years and the collapse of health systems and supporting infrastructure bodes poorly for future health conditions in that war-infected country (Mokdad, et al., 2016, pp. e710, e712). Prolonged armed conflict also has particularly negatively impacted the health of Somalia’s population (McCracken and Phillips, 2017, pp. 320–321). Challenges accessing care State collapse into civil turmoil “has led to humanitarian agencies filling the caretaker void” (Davies, 2010, p. 110). Although neutral humanitarian organizations struggle to keep people alive and hopeful until violent conflict subsides and peaceful conditions return (Duggan, 2008, pp. 287–288, 290–291), the immediate threat of casualties resulting from vicious intrastate assaults on civilian populations (Ottersen, 2014, pp. 651–652) present an often exclusively family- and community-attended crisis concern. Both emergency-health care and long-term rehabilitation are either missing or in short supply and chronic illnesses go unattended8 (McCracken and Phillips, 2017, p. 317; Ager and Hermosilla, 2012, p. 99). Basic public-health infrastructure is eroded by war, and it is nearly impossible to conduct comprehensive epidemiological surveys during protracted periods of violence (Price-Smith, 2009, pp. 177, 185). In areas left with conflict-disrupted and conflict-devastated health systems, dependent surviving populations face enduring inflation in morbidity and mortality risks (Ager and Hermosilla, 2012, p. 85).

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Box 2.3 details the difficulty accessing institutionalized health care that targeted populations can experience in urban centers. In Iraq, when able to reach aid, escapees, and evacuates from Mosul were “‘totally emotionally and physically exhausted’” (Geddo, quoted in Specia and Boshnaq, 2017). Aid agencies were challenged to help the most severely injured and malnourished civilians (Specia and Boshnaq, 2017).

Box 2.3 Direct health impairment through armed force: Kosovo Starting in 1989, when Serbian nationalism was being inflamed by the ruling elite in Belgrade, Kosovar Albanians . . . [were intentionally and effectively discouraged from securing] health care. The actual process of traveling to a hospital was restricted by random detention at checkpoints and lengthy identification checks. The general climate of fear meant that travel to a hospital after dark was impossible. . . . By early 1999, heavily armed police patrolled the main hospital in Pristina, snipers operating from the roof terrorized patients, Albanians who had been injured by violence were increasingly denied treatment, and all Albanian employees of the hospital had been fired. Source: Toole (2006, p. 192)

Destruction of medical facilities The intentional destruction of medical facilities occurs with greater frequency as combatants increasingly target health services in conflict zones as part of a “total war” strategy (Crisp, 2016, p. 132; ICRC, 2015, p. 1).9 Bombing of the Abs Hospital by Saudi jets in August 2016, the fourth health facility in Yemen operated by Doctors Without Borders to come under attack, led the organization to withdraw 550 medical personnel from the country (Mazzetti and Almosawa, 2016; also see Lindley and Hammond, 2014, p. 62; Sengupta, 2017).10 About 65 percent of Yemen’s health facilities have been damaged by the civil war, “denying more than 14 million people access to health care” and contributing to an exceptionally widespread outbreak of cholera that by July 2017 had “infected at least 269,608 people and killed at least 1,614” (Almosawa and Youssef, 2017). Iraqi hospitals have been labeled “killing fields” (Ottersen, 2014, p. 651). By 2014, armed conflict had rendered Syria’s medical facilities in total disarray and targeting of Syrian physicians forced many civilians to flee (Ottersen, 2014, p. 651). Still, deliberate destruction continued in that country; a WHO study found that two-thirds of all attacks on medical centers worldwide in 2016 occurred in Syria (Sengupta, 2017). Conditions often remain perilous for those who remain behind as well. The devastation of health facilities during the civil war that plagued Sierra Leone,

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for instance, is widely credited with limiting the country’s capacity to respond effectively to the Ebola outbreak (Crisp, 2016, p. 132). Needless to say, it often takes years for devastated health sectors to recover capacity to provide essential care and provisions (McCracken and Phillips, 2017, p. 319). Targeted medical personnel Increasingly, moreover, the safety of medical personnel under international humanitarian law (Gunn, 2010, p. 165; Schirch, 2016, p. 300) is no longer respected by combatants (e.g., McCracken and Phillips, 2017, pp. 320, 323; Davies, 2010, p. 129). In Afghanistan, to cite just one case in point, staff killings and abductions forced the Red Cross to terminate its medicine-supply and rehabilitation-center operations in Northern provinces in October 2017 (Abed and Rahim, 2017). Moreover, the use of explosives “inside or within the perimeter of health-care facilities” takes an ill-afforded toll among dedicated healthcare personnel (ICRC, 2015, p. 1). Faced with such threats, the temptation for humanitarian agencies is to request protection from military sources. The dilemma associated with seeking military assistance is that while “cooperation with the military may enhance aid agencies’ capacity to deliver health care in the most difficult environments and ensure some protection for civilians,” the blurring of lines can backfire because “when warring factions are unable to distinguish between civilian humanitarian workers and the military, they do not worry about making the distinction and simply target both” (Davies, 2010, pp. 114–116; also Schirch, 2016, pp. 299–300, 316; Friis, 2016, pp. 268, 270–271). Civilian populations, consequently, often lose trust in the humanitarian effort (Schirch, 2016, p. 317). “First killer is flight” It is understandable that many people opt to flee from armed conflicts and repressive governments that threaten their health and mortality status. For survivors, the road ahead is paved with peril. An African war zone study carried out by Physicians for Human Rights concluded that the “first killer is flight” for desperately poor persons driven by conflict from a fragile existence into a hostile and personally threatening environment where health services are nonexistent or not functioning (Lacey, 2005). In 2016, a record 4,579 asylum seekers and others perished trying to reach Italy from Libya across the “so-called Central Mediterranean route” (Kanter, 2017). Increasingly, children journeying alone are transnational refuge seekers (Sengupta, 2016). Although trustworthy and helpful intermediaries can be a life-saving option, persons who engage smugglers remain vulnerable to exploitation (Mavroudi and Nagel, 2016, p. 143) and death as at least 54 desperate teenagers from the Oromia regions of Ethiopia and Somalia experienced when they perished after smugglers forced them into the sea en route to war-ravaged and cholera-infested Yemen in August 2017 (Al-Batati, 2017; also see Montgomery, Fernandez, and Joseph, 2017).

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Refugees, asylum seekers, and “people of concern”: physical- and mental-health conditions in camps, settlements, and detention centers Most conflict-induced migrants who cross borders flee to low-income and middle-income countries. As Susan Martin and Roger Zetter (2012, p. 17; also p. 24) note, “people often flee conflict-ridden and failed states, only to find themselves in almost equally unstable situations – Afghans in Pakistan, Iraqis in Syria and Somalis in Yemen.” Seven years of internal armed conflict displaced about six-in-ten of Syria’s pre-conflict population, nearly 13 million people, by 2017, according to Pew Research Center estimates; most of those who have fled Syria remain in the Middle East.11 Forced displacement creates urgent and demanding problems for multiple Southern countries. As soon as persons fleeing conflict or persecution reach a place of safety, they often “require urgent medical attention in order to avoid further mortality and morbidity” (Pottie, Hui, and Schneider, 2016, p. 299). At Kenya’s Dadaab refugee camp near the border with Somalia, “mothers with babies wrapped in bundles on their backs sometimes did not know, until they reached the camp and untied their bundles, that their babies had died along the way” (Gettleman, 2017, p. 286). Psychiatric disorders often are associated with forced migration, disrupted family ties, and personal insecurity (Toole, 2006, pp. 192–193; McMichael, Barnett, and McMichael, 2012, p. 649; Kamara and Renzaho, 2016, pp. 95, 97). The combination of psychological stress and malnutrition results in increased likelihood of immunosuppression. In short, “with their mobility, malnourishment, lack of adequate shelter, and limited access to sufficient medical care, refugees are highly vulnerable to pathogenic colonization” (Price-Smith, 2009, p. 162; also p. 185). At the same time, health-dependent social networks and assets are left behind and permanently lost (McMichael, Barnett, and McMichael, 2012, p. 648). In addition, refugees can “serve as conduits of infection to other proximate countries” (Price-Smith, 2009, p. 177). Although refugees “are often portrayed as disease carriers or burdens on national health resources,” their arrival does not always play out in zero-sum fashion (Davies, 2010, p. 87). Camps and settlements feature in the locational distribution of conflict-provoked migrants. Camps refer to living places where inhabitants are dependent on external assistance. In contrast, the term “settlement” indicates that residents are primarily “responsible for their own subsistence,” although in some cases aid agencies still provide for education and health care (Mavroudi and Nagel, 2016, p. 137). In terms of health conditions, refugee camp residents appear most often in the international media .  .  ., [although] the even larger numbers of people who are internally displaced and the people who ‘self-settle’ in regional towns and cities constitute a hugely important, if less visible and accessible component of displacement. (Lindley and Hammond, 2014, p. 67)

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For instance, nearly two-thirds of the Syrian refugees who arrived in Lebanon live outside camps – “scattered over 1,000 municipalities, most of which are in impoverished urban areas” (Kamara and Renzaho, 2016, p. 89). Internally displaced persons (IDPs) and persons who flee across borders populate both camps and settlements. Syria, Nigeria, Sudan, and the Democratic Republic of Congo (DRC) currently account for particularly large numbers of IDPs (Renzaho, 2016a, p. 34; de Freytas-Tamura, 2017). Pakistan, Iran, Lebanon, Jordan, and Turkey all host more than half a million persons forced to flee their home country by armed violence (Pottie, Hui, and Schneider, 2016, p. 293).12 In both displacement situations, people living in receptor areas become vulnerable to negative health effects due to the influx of infectious diseases and additional burdens placed on local health facilities (Whitaker, 1999; McMichael, Barnett, and McMichael, 2012, p. 650).13 It is important, therefore, that additional (often long-term) health resources be made available, preferably through community-based organizations, to both newcomers and existing inhabitants in recipient places (McCracken and Phillips, 2017, p. 311; Martin, et al., 2017, pp. 111–112).14 According to UNHCR estimates, more than 500,000 asylum applications from Syrians alone have been submitted in Europe since the start of the conflict in that country (cited in Pottie, Hui, and Schneider, 2016, p. 293). However, Northern states prefer and actively pursue containment strategies – “in the [Southern] region of origin, in border zone refugee camps, and through repatriation to ‘safe havens’ within the country of origin” (Lindley and Hammond, 2014, p. 68). Camps Today, millions of externally and internally displaced people are forced to live, often for long periods and even for multiple generations (Lindley and Hammond, 2014, p. 67), in camps. Some camps approach the population size of cities (Koser and Martin, 2011, p. 3). “Protracted refugee situations” of five years or longer in exile are the norm (Larocca, 2018). While camps offer shelter, food, and initial reductions in mortality, crowding and poor sanitary conditions compound the risks of illness and death from communicable diseases (Toole, 2006, p. 196; Ager and Hermosilla, 2012, p. 84). Diarrheal diseases, acute respiratory infections, and malaria (in tropical contexts) rank among the primary causes of morbidity and mortality in refugee camps (Kamara and Renzaho, 2016, pp. 84, 87). Women “face additional reproductive health risks: elevated risks of maternal mortality, unmet needs for family planning, limited access to clinical health services, complications after unsafe abortions, and gender-based violence” (McMichael, Barnett, and McMichael, 2012, p. 649; Penttinen and Kynsilehto, 2017, p. 36; Ager and Hermosilla, 2012, pp. 84–85). The elderly and children also are especially vulnerable; children “are particularly at risk from malnutrition, as well as violence, abduction into militias and disease due to malnourishment and poor immune defense” (Davies, 2010, p. 90). Too often, the intercultural-communication assets of refugees tend to be ignored, with negative consequences for camp health (Ngai and Koehn, 2002).

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In 2016, MSF staff found “extremely high severe acute malnutrition in children” and hundreds of deaths from diarrheal diseases in the Bama camp for IDPs on the outskirts of Maiduguri, Nigeria (Burki, 2016; also see Kamara and Renzaho, 2016, pp. 91–95). In Pakistan, “hepatitis B is highly endemic among Afghan refugees living in camps in Baluchistan and the NWFP” (Rajabali, et al., 2009, p. 611). High measles-attack rates occurred in Mozambican refugee camps in Malawi, among Vietnamese refugees in Hong Kong and Cambodian refugees in Thailand, and in other high-population-density camps (Kamara and Renzaho, 2016, p. 85). Rohingya refugee and internally displaced children are notoriously disadvantaged. A 2013 study found that in camps for IDPs around Sittwe in Rakhine State, Myanmar, rates of diarrheal illnesses and mortality for children younger than five years were far higher than for children not living in camps (Ives, 2016). By 2012, an estimated 500,000 displaced persons inhabited the Dadaab camp complex, the third-largest population center in Kenya after Nairobi and Mombasa (Lindley and Hammond, 2014, p. 60).15 Arriving Somalis inhabit selfconstructed shelters built of sticks and cloth, and thousands of camp dwellers “squat in wastelands or live in the energy-sapping humidity of tents supplied by the U.N. High Commissioner for Refugees” (Muhumed, 2011). In spite of the presence of a network of three hospitals and 22 health posts operated by five NGOs (Ager and Hermosilla, 2012, p. 87), a spreading cholera epidemic hit the Dadaab complex in 2015.16 On the positive side of the ledger, researchers found the prevalence of HIV among refugees living in Dadaab to be lower than the prevalence in the neighboring sentinel site (Kamara and Renzaho, 2016, p. 87). In contrast to prevailing conditions in many camps for refugees, the Finnish Red Cross (FRC) operation in Northern Greece provides a model for emergencyhealth care. In addition, although already strained to meet the country’s own population’s needs, Greece has “graciously accepted referrals to district and tertiary care hospitals” and cooperation by the Hellenic Red Cross has been “fantastic” (Morgan, 2016). Box 2.4 excerpts from a 2016 interview with Mahmood Elahi, senior medical officer seconded by the Canadian Red Cross working in the region with FRC.

Box 2.4 Basic Health Care Units (BHU) operated by the Finnish Red Cross in Northern Greece Each camps holds between 1500 and 2000 people, who possess access to toilets, showers, and waterproof shelters, but not electricity and running water. The BHU stocks commonly used medicines that are dispensed at no cost to patients.  .  . . Prenatal and midwifery care is provided in the Maternal Child Unit and a psychological support worker arrives weekly for consultations. The [BHU] . . . works closely with partner

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groups and agencies such as the hygiene promotion team, visiting dental teams, and mental-health-care workers. In these refugee camps, there have been “no outbreaks or elevated mortality” or “visible signs of malnutrition.” Source: Morgan (2016)

Ensuring adequate security within refugee camps also can be challenging (Koser and Martin, 2011, p. 3). The highly valued relief items distributed by NGOs can make camp recipients targets for attack (Duggan, 2008, p. 290) and camp managers typically are neither authorized nor positioned to provide protection for vulnerable refugee populations (Davies, 2010, pp. 97–98). In Somalia during the early 1990s, Médecins Sans Frontières “was only able to operate a surgical facility if it paid for [and gave priority treatment at gunpoint to] a local security force that eventually turned on MSF after the NGO questioned the rising payments required for protection” (ibid., p. 93). This situation alerts us to the possibility that medical assistance delivered with neutral intentions can involve unintended conflict-exacerbating and conflict-extending political and health consequences (ibid., pp. 94–95, 105, 118–120). In spite of the many serious challenges confronted, the medical assistance provided by NGOs is vitally important for the health of refugee populations. In the late 1990s, the Sphere Project and the minimum standards set forth in its Humanitarian Charter articulated “technical measures for increasing the effectiveness of humanitarian aid, including areas such as minimum daily nutrient intake, the size of tents and access to water” (ibid., p. 111).17 U.N. agencies, MSF, Oxfam, and Save the Children all more than satisfy Sphere guidelines. In some cases, the assistance provided in refugee camps is superior to the health care available to surrounding populations. This situation calls for the simultaneous upgrading of health services to local people in order to ensure undifferentiated care and to avoid provoking resentment (ibid., pp. 98, 110). In addition, systematic intercultural-communication and transnational-competence training is essential in preparing multinational responders for the diverse camp and host populations they will encounter (see Ngai and Koehn, 2014; Koehn and Ngai, 2014, pp. 290–298, 302–312). Settlements Millions of refugees and IDPs spontaneously settle in urban areas; they arrive with diverse migration backgrounds, vulnerabilities, assets, expectations, and aspirations (Haysom, Pantuliano, and Davey, 2012, pp. 113–114, 117, 130–132). In many places, sprawling and densely populated self-settled areas support massive numbers of transnationally displaced persons. The homeless among them are particularly vulnerable to contracting infectious diseases and suffering permanent damage to their physical and mental health (see Stuckler and Basu,

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2013, pp. 127, 129). Thus, psychosocial-support “has become a major area of humanitarian programming” (see Ager and Hermosilla, 2012, pp. 96–98; Haysom, Pantuliano, and Davey, 2012, pp. 128–130). Following the forced displacement of upwards of 400,000 people from Mogadishu neighborhoods in 2007 and 2008, many of the Somali IDPs lived in the Afgoye corridor, insecure settlements with “poor shelter, sanitation, and water access, eking out a living through begging, casual work, and intermittent humanitarian assistance” (Lindley and Hammond, 2014, pp. 55, 58). Recurrent food shortages and sustained malnutrition afflicted IDPs along with those Somalis whose strategic agency was constrained by involuntary immobility (ibid., pp. 65, 67; Martin and Zetter, 2012, pp. 21–22). Lindley and Hammond (2014, pp. 67–68) observe that migration in failed states “is certainly often a source of great suffering, but it is also a vital means to negotiate crisis . . . [that] may be preferable to the alternatives.” However, host communities, along with local hospitals and other health infrastructure, often are overwhelmed by the numbers of arriving conflict-induced IDPs and transborder migrants (Haysom, Pantuliano, and Davey, 2012, pp. 116–118, 123).18 In Southern host-countries, conflict-generated transmigrants who live outside official camps usually are “among the poorest and most vulnerable” residents who must share services that previously “were inadequate even when used by a smaller population” (Martin, et al., 2017, p. 111). About 1.5 million Afghan refugees inhabited urban areas in Pakistan in 2008 and the “mass movement of displaced populations facilitated the spread of communicable disease.” In densely populated Afghan-refugee settlements on the outskirts of Karachi, furthermore, standards of sanitation and hygiene and access to trained medical care were “well below optimum” (Rajabali, et al., 2009, pp. 610–611; also see McMichael, Barnett, and McMichael, 2012, p. 648). In response to similar conditions, IFRC and the Jordanian Red Crescent Society “facilitated access to health care for unregistered refugees [in Jordan] with an innovative cash transfer scheme engaging local health service providers” (Ager and Hermosilla, 2012, p. 87; also see Haysom, Pantuliano, and Davey, 2012, p. 133; Levine, 2012). In Bangladesh, a massive unofficial camp (a dense collection of bamboo and tarp huts) populated by several hundred thousand Rohingya who fled uprooting in Myanmar exists alongside the official UNHCR camp. There are no toilets and “every medical treatment post . . . has a line that snakes nearly around the camp” (Solomon, 2017). Just over 200 hospital beds are available for nearly one million forcibly displaced Rohingya living in conditions described in October 2017 by Joanne Liu, international president of Doctors Without Borders, as a “‘time bomb ticking toward a full-blown health crisis’” (Cumming-Bruce, 2017b; also see Chan, Chiu, and Chan, 2018). For the 30 percent of the Rohingya refugee population under age 5, exposure to horrific trauma, hyperstressed conditions, and developmental setbacks due to malnutrition in such settlements portend a “‘massive mental health crisis for children,’” according to Lalou Holdt, Save the Children’s mental health adviser (Beech, 2018). Here, soccer provides a “joyful escape” from unhealthy living conditions.19 A 24-year-old, second-generation Rohingya refugee, Mohammed Ismail, explained to a New York Times reporter,

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“‘When I play football, the sadness and anger is far away. But after I finish, it always comes back’” (Thompson, 2017; also see Koehn and Koehn, 2016). Detention centers An August 2016 Amnesty International (AI) report details the abuses and negative health consequences associated with confinement in Syria’s prisons, including “prolonged periods of solitary confinement; severe overcrowding of cells; lack of adequate access to medical treatment, sanitation, food, and water; exposure to extreme temperatures; and prolonged detention for hours or days in cells containing the bodies of deceased detainees” (AI, 2016, p. 7). Conditions experienced in Syria’s detention centers often are lethal; from 2011 through 2015, conservative estimates indicate that more than 17,000 detainees died in custody across Syria (AI, 2016, p. 7). At the Guantánamo Bay detention center for accused terrorists, the International Committee of the Red Cross (ICRC) uncovered the systematic and sophisticated use of psychological and physical torture, often in collusion with medical staff.20 U.S. Central Intelligence Agency physicians and psychologists involved in interrogation subjected post-9/11 detainees transported from overseas locales to life-threatening and life-scarring torture – including simulated drowning, prolonged shackling in painful positions, hiding drugs in food, forcible rectal hydration, and extended sleep deprivation (Bloche, 2016). Throughout the world, Guantánamo “has become a symbol of injustice, abuse, and disregard for the rule of law.”21 Fueled by a “‘climate of xenophobia’” (Filippo Grandi, cited in Sengupta, 2016) and political disruption stoked by resurgent nationalism (Garcia-Zamora, 2017, pp. 581, 585, 588), the United States and European countries also hold many known asylum seekers in detention centers. According to Amnesty International estimates, “approximately 600,000 men, women, and children are detained in Europe annually” (cited in Pottie, Hui, and Schneider, 2016, p. 294). Child migrants present especially challenging physical- and mental-health conditions. Caring for child refugees “fleeing conflicts in places like Syria, Afghanistan, and Eritrea requires special skills that many staff members at [European] asylum centers do not have” (Sorensen, 2016). In some cases, asylum seekers are mistreated as criminals and are held in detention centers for lengthy periods. Australia herds asylum seekers into unsafe and unhealthy offshore-processing centers that have been labeled “island prisons” (Cohen, 2016). For detained asylum seekers and prisoners who eventually are released, the ordeal continues. Most survivors “continue to face difficulties, in particular with their health, both psychological and physical, long after their release” (AI, 2016, p. 8).

Responding-agency roles, responsibilities, and durable-outcome challenges When requested by migrant-receiving states, UNHCR is responsible for camp management, shelter provision, and coordinating the activities of responding

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agencies in cross-border displacements resulting from conflict situations. The International Federation of Red Cross and Red Crescent Societies leads the cluster of agencies that deal with health protection (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 117; Martin and Zetter, 2012, p. iii). It is important to recognize that persons fleeing persecution and armed conflict, while especially vulnerable, “are not passive figures in forced migrations; rather, they have an active, if subordinate, role in shaping these migrations” (Mavroudi and Nagel, 2016, p. 143; also Lindley and Hammond, 2014, pp. 67–68)22 and in determining personal and family health and well-being in destination places.23 At the same time, refugees and other forcibly dislocated men, women, and children can bring serious health conditions with them when they move transnationally (Crisp, 2016, p. 132). In positive outcome cases, conflict-provoked migrants find safe and sustainable living conditions where their physical- and mental-health needs can be fully addressed, often with help from local NGOs, social workers (Koehn and Rosenau, 2010, Chapter 8), and caring individuals. Situations where protection and assistance are no longer needed often take years to realize. Durable outcomes can involve local integration, relocation abroad,24 or secure repatriation to the country of origin (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 85). UNHCR and IOM are critical mitigating actors in the extensive, expensive, prolonged, and often opaque nature of the refugee-settlement process (see Kaiser, 2014, p. 193). In many cases, resolving “displacement is actually likely to involve facilitating continued migration” (Stoddard, et al., 2012, p. 225; emphasis in original). Official refugees undergo health screenings that typically are missing in the case of irregular and undocumented migrants. Secure repatriation is promoted by systematic attention to training programs that are tailored to the needs of the country of origin (Koehn, 1994, pp. 8–9).25 Hasty or forced repatriation schemes that are negligent regarding the infection reservoir carried by vulnerable repatriates increase the risk that communicable diseases will be spread among receiving populations (Rajabali, et al., 2009, p. 613). Medical treatment, then, constitutes one of several critical responses required for successful repatriation (see Lindley and Hammond, 2014, p. 68; Koehn, 1994, 1995; WHO, 2010, p. 53).

Health as a bridge to peace The challenge the world faces is reversing the vicious cycle so that health becomes a promising bridge to peace rather than a negative consequence of conflict. WHO’s Constitution thoughtfully points us in this direction by recognizing that “the health of all peoples is fundamental to the attainment of peace and security.”26 Embracing this challenge begins with concerted upstream efforts to address the transnational structural factors that undermine global health – that is, preventive advocacy and actions that address the multiple political and social determinants leading to “the eruption of violence” (Santa Barbara and Arya, 2008, p. 10; also Lyon, Kim, and Farmer, 2008; Ager and Hermosilla, 2012, pp. 92–94) and the shrinking of protective space (Zetter and Horst, 2012,

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pp. 68, 70). This step forward requires that “global health governance .  .  . be developed to ensure effective collective action on the [underlying] global factors that determine health” (Kanth, Gleicher, and Guo, 2013, p. 287; Stoddard, et al., 2012, pp. 233–234). In the interim, students of global health at universities in Canada, Finland, Uganda, and El Salvador, among other places, have been in the forefront of advocacy for peace through health (Buhmann and Pinto, 2008, pp. 293–296). Engagement by medical personnel in peacemaking and conflict resolution initiatives constitutes another bridge to forestalling violence and preventing dire health consequences (Rushton, 2008, pp. 16, 18). As a common and transcendent goal, community health can unite conflicting parties (Davies, 2010, p. 121). In addition, medical aid NGOs are occasionally able to use health reasons to achieve temporary ceasefires; . . . it is hoped that during these windows of calm, major actors in the violent conflict will experience the advantages of peace and advocate for it to continue. (Duggan, 2008, p. 291) At minimum, there is peace-building value in Oxfam’s “safe programming” (do-no-harm) approach – i.e., ensuring that water, sanitation, and hygiene projects “do not inadvertently put affected populations in further danger and that aid does not negatively impact on conflict dynamics” (cited in Zetter and Horst, 2012, p. 59). Consistent with this ethical principle, MSF withdrew from Goma camps in Zaire because of “mounting concerns that aid was unwittingly contributing to the strengthening of armed forces seeking refuge in the camps, who were planning to commit further mass atrocities and contribute to the continuation of conflict across the border in Rwanda” (Davies, 2010, p. 93). Health workers are both uniquely positioned to advance prospects for conflict resolution and challenged to overcome skill deficits, combatant perceptions, and responsibility overload (MacQueen, 2008, pp. 23–25). Training for field-based health practitioners in mediation and conflict transformation is advantageous in this connection (MacQueen and Santa Barbara, 2008, pp. 33–35). Joanna Santa Barbara (2008a, 2008b, pp. 151–160) offers particularly helpful suggestions for analyzing and approaching peace-through-health situations (also see BundeBirouste and Zwi, 2008; Arya, Melf, and Buhmann, 2008, p. 305). An additional dimension of the “health as a bridge to peace” approach involves improved planning for and contextual treatment of the health conditions that characterize post-conflict situations.27 Nigel Crisp (2016, p. 132) insightfully emphasizes that “understanding the impact of specific conflicts on affected populations is essential if the global community is to respond with appropriate resources and plans for the post-conflict environment, when health systems often have to be rebuilt in totality.” The peace-promoting properties of post-conflict programs aimed at rehabilitating and integrating persons with disabilities (see

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Boyce, 2008) are especially compelling. In the war-torn city of Hargeisa (today the peaceful capital of Somaliland), for instance, the Center for International Humanitarian Cooperation (CIHC) used modest resources to establish a highly visible rehabilitation facility with services available without charge to all amputees. In the words of Dr. Kevin Cahill (2017, p. 25), “few examples” of restored health service “are as dramatic as hundreds of formerly handicapped persons suddenly able to walk around town.” In an important dimension of the project that ensured its success and sustainability, Somalis participated in its planning and exclusively operated the center (ibid., pp. 25, 28). Social healing and restoring positive and fruitful connections among diverse populations are critical components in the peace-through-health approach. Prospects for reversion to violence can be greatly diminished by early investments in health care accompanied by bringing groups together to plan the health system, forming multiethnic teams for this task and for subsequent health delivery, making care equally accessible to all, and respecting the cultural needs of all groups in the design of health care and its facilities. (MacQueen and Santa Barbara, 2008, pp. 39–42; also Davies, 2010, pp. 121–122)

Notes 1 UNHCR maintains that people fleeing war-related conditions and generalized violence “should be treated as refugees as the precise source of persecution should not be decisive” (Davies, 2010, p. 89; emphasis in original). 2 By 2017, according to Solomon (2017), the European Union, UNHCR, and the African Union all emphasized “migration management” by Ethiopia in order to confine migrants from South Sudan, Eritrea, and Somalia within the country’s borders (also see Garcia-Zamora, 2017, p. 585; Nossiter, 2018). The EU also supported “migration management” by Sudan along its eastern border with Eritrea (Kingsley, 2018). Further north, the migration-control arrangements with Libya negotiated by Italy and supported by the EU have trapped thousands of African migrants in overcrowded and inhumane “slave-like conditions” (Kirkpatrick, 2017). 3 In Nganza, DRC-government security forces went house to house in March 2017, slaughtering more than 500 elderly and disabled persons, newborns, and others in their “beds and living rooms” (de Freytas-Tamura, 2017). 4 In September 2017, Zeid Ra’ad al-Hussein, U.N. High Commissioner for Human Rights, accused Myanmar of conducting “a textbook example of ethnic cleansing” against Rohingya Muslims (Cumming-Bruce, 2017a, p. A9; also see Taub, 2017; Beech, 2017). 5 Similarly, Al Shabaab in Somalia “tried to contain people inside the area it controlled, forcing back those who tried to flee, beheading the drivers of vehicles found to be smuggling people out, and forbidding people to leave” (Lindley and Hammond, 2014, p. 59). Prior to retreating from Qaryatayn, Syria, in October 2017, ISIS fighters “killed scores of civilians, dumping some bodies into wells and leaving others in the street” (Barnard, 2017; also see Gladstone, 2017c). 6 This term is drawn from Peter Mauer’s 2017 field observation that the scale of hardships wrought by conflict in South Sudan is indicative of “a style of suffering that

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10 11 12 13 14

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16 17 18 19

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appears calibrated to maximize misery” (cited in Cumming-Bruce, 2017c). Mauer is President, International Committee of the Red Cross. On infant and child starvation in Nigeria’s Borno State stemming from military conflict between government forces and Boko Haram, see New York Times, 24 January 2017, p. D4. Most strikingly, among Palestinian refugees, an aging population coupled with changes in diet and lifestyle “have resulted in a situation where between 70 and 80 percent of deaths are now attributable to non-communicable diseases such as cardiovascular disease, diabetes, and cancer” (Ager and Hermosilla, 2012, p. 89). In rural and remote areas, appropriately staffed and effectively advertised mobile clinics can play a vital emergency role in reaching persons engulfed in conflict who are unable or too shaken and distressed to seek out stationary facilities (Pottie, Hui, and Schneider, 2016, p. 300; WHO, Commission, 2008, p. 71). Local Red Cross workers were killed and injured in January 2017 when a Nigerian Government jet mistakenly bombed a camp for people who had fled Boko Haram militants (Searcey, 2017b). https://pewresearch.us1.list-manage.com/track/click?u=434f5d1199912232d416897 e4&id=2b05c4bdc0&e=e3bfd228a0; accessed 14 February 2018. Ethiopia hosted more than 140,000 Eritrean refugees and asylum seekers in 2015 (Solomon, 2017, p. 8). Lebanon’s limited capacity to handle the rapid influx of Syrian refugees created a particularly acute health burden (Kamara and Renzaho, 2016, p. 81). Beth Whitaker (1999) found, for instance, that, in the wake of the refugee influx, donors eventually expanded and enhanced the health system throughout western Tanzania and that Tanzanians also “were provided services free of charge” at refugeehealth facilities. See “Health, nutrition, water, sanitation and hygiene in Dadaab refugee camp.” www. ifrc.org/Global/Documents/Africa/201606/Health,%20nutrition,%20water,%20 sanitation%20and%20hygiene%20in%20Dadaab%20refugee%20camp.pdf; accessed 11 August 2017. Médecins Sans Frontières. “Mexico: An unsafe country for thousands of refugees fleeing violence in Central America.” www.msf.org/en/article/kenya-cholera-outbreakspreads-dadaab-refugee-camp; accessed 11 August 2017. The Sphere Project’s emphasis on technical approaches, rather than on steps to end conflicts, has been faulted by MSF among others (Davies, 2010, pp. 110–113). This situation occurred in Maiduguri, Nigeria, in 2016 (Burki, 2016). Two of the six reasons the Swedish parliamentarian Lars Gustafsson set forth when he nominated soccer for the Nobel Peace Prize in 2001 are (1) it promotes “peace and understanding” within and among peoples, and (2) it cultivates “a public meetingplace with no hindering boundaries” (Bar-On, 2017, p. 189; see also Charlton, 2018). See International Committee of the Red Cross. www.nybooks.com/media/doc/2010/ 04/22/icrc-report.pdf. ACLU. “Guantánamo Bay Detention Camp.” www.aclu.org/issues/national-security/ detention/guantanamo-bay-detention-camp; accessed 7 August 2017. As Roger Zetter and Cindy Horst (2012, p. 64) note, “moving out of a war zone is often one of the most effective protection mechanisms for people affected.” In the long term, however, the consequences of displacement can be extremely harmful (ibid., p. 65). On the flexible application of extended-family networks by refugees as valuable protective resources in the face of forced-migration challenges, see Kaiser (2014, pp. 183, 189, 194–196, 198–200). In 2017, President Donald Trump imposed a limit of 45,000 annual refugee admissions to the USA – the lowest number in more than three decades (Baker and Liptak, 2017). In the face of continued persecution prospects and unsafe conditions, however, refugees understandably resist premature return to the sending-country.

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necessary while protecting the rights of refugees and other migrants. The declaration in turn launched a two-year process in which these same governments agreed to negotiate Global Compacts on Safe, Orderly and Regular Migration and on Refugees, to be adopted by the end of 2018. The rhetoric in both compacts is generally positive about migration, but the true test will be implementation of these agreements. In this context, there has also been a growing body of evidence as to the interconnections between international migration and other global issues. The nexus between migration and development has received the most attention in terms of both research and policymaking. The literature is vast, although new dimensions of the relationship continue to unfold. Importantly, migration indicators were in the Sustainable Development Goals adopted as part of Agenda 2030, thereby acknowledging that movements of people affect their own human development as well as the economic development of their home countries. The nexus between migration and the environment is another area receiving attention from both academics and policymakers. Research on the complex interconnections, especially between the effects of climate change and human mobility, alerted policymakers to three forms of movement resulting from environmental change – migration (that is, anticipatory movements of individual households), displacement (that is, mass movements of people because of sudden events), and relocation (that is, planned movements of communities generally involving some governmental support). To date, most attention is on displacement. The parties to the UN Framework Convention on Climate Change established a taskforce to make recommendations on displacement, and the global compact on migration makes recommendation for more effective prevention and responses to these movements. A coalition of UN agencies, with support from Georgetown University, have developed principles and identified effective practices for internal relocation related to environmental changes, and is providing training and technical assistance to governments. Comparatively less attention has been placed on anticipatory environmental migration by individuals and households, an important area requiring considerably greater attention. There have also been advancements in the understanding of the nexus between migration and health – which is the direct focus of this book. Just as migration can no longer be seen as an issue to be addressed by states working in isolation, health problems cannot be addressed solely within borders. Concerns about the impact of migrants on the health of natives as well as the cost of health care have been one source of alarm about migration in general, although, at least in the United States, these concerns have generally been overblown. Yet, with millions of travelers on the move each day, containing epidemics becomes more difficult and certainly requires international cooperation. At the same time, ensuring healthy lives for migrants and refugees requires transfer of data across borders as well as the sharing of expertise. Efforts to ensure that international migration does not aggravate health care access in developing countries, in a way that does not abridge the right of health professionals to move to where they may have greater opportunities, require substantial international cooperation as well.

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Cahill, Kevin M. 2017. Milestones in Humanitarian Action. New York: Fordham University Press. Chan, Emily Ying Yang; Chiu, Cheuk Pong; and Chan, Gloria K.W. 2018. “Medical and Health Risks Associated with Communicable Diseases of Rohingya Refugees in Bangladesh 2017.” International Journal of Infectious Diseases 68:39–53. Charlton, Angela. 2018. “Diversity Is Soccer’s New Normal.” Missoulian, 11 July, p. C5. Cohen, Roger. 2016. “Australia’s Death by Numbers.” New York Times, 31 December, p. A21. Connor, Phillip. 2018. “Most Displaced Syrian Are in the Middle East, and about a Million Are in Europe.” Pew Research Center Fact Tank, 29 January. Crisp, Nigel. 2016. One World Health: An Overview of Global Health. Boca Raton, FL: CRC Press. Cumming-Bruce, Nick. 2017a. “Rohingya Crisis Called Ethnic Cleansing.” New York Times, 12 September, p. A9. Cumming-Bruce, Nick. 2017b. “Rohingya Refugee Count Is Set to Top One Million.” New York Times, 24 October, p. A8. Cumming-Bruce, Nick. 2017c. “Strife and Hunger Send South Sudanese Fleeing to Uganda.” New York Times, 18 August, p. A6. Davies, Sara. 2010. Global Politics of Health. Cambridge, UK: Polity Press. de Freytas-Tamura, Kimiko. 2017. “Congo’s Mass Graves Multiply, But the Military Wants Silence.” New York Times, 28 July, pp. A1, A10. Dickenson, Elliot. 2017. Globalization and Migration: A World in Motion. Boulder, CO: Rowman & Littlefield. Duggan, Ann. 2008. “A Role for Emergency Humanitarian Aid Organizations in Peace?” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 287–292. Fine, Ben; and Saad-Filho, Alfredo. 2014. “Politics of Neo-Liberal Development: Washington Consensus and Post-Washington Consensus.” In The Politics of Development: A Survey, edited by Heloise Weber. London: Routledge. Pp. 154–166. Fink, Sheri. 2017. “Ex-Detainees Reach Settlement with 2 Psychologists in C.I.A. Torture Case.” New York Times, 18 August, p. A12. Friis, Karsten. 2016. “Norwegian Approach to Afghanistan: Civilian-Military Segregation.” In Unity of Mission: Civilian-Military Teams in War and Peace, edited by Jon Gundersen and Melanne A. Civic. Maxwell Air Force Base. Alabama: Air University Press. Pp. 263–278. Garcia-Zamora, Jean-Claude. 2017. “The Global Wave of Refugees and Migrants: Complex Challenges for European Policy Makers.” Public Organization Review 17:581–594. George, Susannah; Abdul-Zahra, Qassim; Michael, Maggie; and Hinnant, Lori. 2017. “Cost to Oust Islamic State from Mosul: At Least 9,000 Civilians.” Missoulian, 21 December, p. A10. Gettleman, Jeffrey. 2017. Love, Africa: A Memoir of Romance, War, and Survival. New York: HarperCollins. Gladstone, Rick. 2017c. “U.N. Says ISIS Executed Hundreds in Iraqi City.” New York Times, 3 November, p. A8. Gunn, S. William A. 2010. “The Humanitarian Imperative in Major Health Crises and Disasters.” In Understanding the Global Dimensions of Health, edited by S.W.A. Gunn. New York: Springer. Pp. 159–168. Gutlove, Paula. 2008. “Psychosocial Healing.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 225–231.

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Haysom, Simone; Pantuliano, Sara; and Davey, Eleanor. 2012. “Forced Migration in an Urban Context: Relocating the Humanitarian Agenda.” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 113–143. Hubbard, Ben. 2017. “Another Casualty of the Syria War: Drinking Water in Damascus.” New York Times, 5 January, p. A6. International Committee of the Red Cross (ICRC). 2015. Health Care in Danger: Violent Incidents Affecting the Delivery of Health Care. Geneva: ICRC. Ionesco, Dina; Mokhnacheva, Daria; and Gemenne, Francois. 2017. The Atlas of Environmental Migration. London: Routledge. Ives, Mike. 2016. “Study Finds Medical Bias against a Muslim Group.” New York Times, 6 December, p. A6. Jacobs, Andrew; and Richtel, Matt. 2017. “With Nafta, Mexico Receives Unexpected Import: Obesity.” New York Times, 12 December, pp. A1, A14–A15. Kaiser, Tania. 2014. “Crisis? Which Crisis? Families and Forced Migration.” In Crisis and Migration: Critical Perspectives, edited by Anna Lindley. London: Routledge. Pp. 181–202. Kaldor, Mary. 2012. New & Old Wars: Organized Violence in a Global Era, 3rd edition. Stanford, CA: Stanford University Press. Kamara, Joseph; and Renzaho, Andre M.N. 2016. “The Social and Health Dimensions of Refugees and Complex Humanitarian Emergencies.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 73–122. Kanter, James. 2017. “Europe’s Leaders Aim to Slow Migration on Dangerous Sea Route from Africa.” New York Times, 4 February, p. A6. Kanth, Priyanka; Gleicher, David; and Guo, Yan. 2013. “National Strategies for Global Health.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 285–303. Kingsley, Patrick. 2018. “Sudan Blocks Migrants’ Path, Aiding Europe.” New York Times, 23 April, pp. A1, A9. Kirkpatrick, David D. 2017. “Europe Wanted Migrants Stopped: Now Some Are Sold as Slaves.” New York Times, 1 December, p. A9. Koehn, Justin; and Koehn, Jason. 2016. “Beach Volleyball with Refugees: A Testimonial.” Jeanette Rankin Peace Center Newsletter (Winter/Spring):4. Koehn, Peter H. 1991. Refugees from Revolution: U.S. Policy and Third-World Migration. Boulder, CO: Westview Press. Koehn, Peter H. 1994. “Refugee Settlement and Repatriation in Africa: Development Prospects and Constraints.” In African Refugees: Development Aid and Repatriation, edited by Howard Adelman and John Sorenson. Boulder, CO: Westview Press. Pp. 97–116. Koehn, Peter H. 1995. “Repatriation of African Exiles: The Decision to Return.” In Cambridge Survey of World Migration, edited by Robin Cohen. Cambridge: Cambridge University Press. Pp. 347–352. Koehn, Peter H.; and Ngai, Phyllis B. 2014. “Managing Refugee-Assistance Crises in the Twenty-First Century.” In Crisis and Emergency Management: Theory and Practice, edited by Ali Farazmand. Boca Raton, FL: CRC Press. Pp. 287–316. Koehn, Peter H.; and Rosenau, James N. 2010. Transnational Competence: Empowering Professional Curricula for Horizon-Rising Challenges. Boulder, CO: Paradigm Publishers. Koser, Khalid; and Martin, Susan. 2011. “The Migration-Displacement Nexus.” In The Migration-Displacement Nexus: Patterns, Processes, and Policies, edited by Khalid Koser and Susan Martin. New York: Berghahn Books. Pp. 1–13.

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Lacey, Marc. 2005. “In Africa, Guns Aren’t the Only Killers.” New York Times, 25 April. Larocca, Rachel. 2018. “Montana to Africa: Refugee Health in Missoula.” Presentation at The University of Montana, Missoula, Montana, 7 March. Levine, Simon. 2012. “Aid Is Dead: Long Live the Market?” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 195–196. Lindley, Anna; and Hammond, Laura. 2014. “Histories and Contemporary Challenges of Crisis and Mobility in Somalia.” In Crisis and Migration: Critical Perspectives, edited by Anna Lindley. London: Routledge. Pp. 46–72. Lyon, Evan; Kim, Jim Yong; and Farmer, Paul. 2008. “Social Injustice and the Responsibility of Health-Care Workers: Observation, Assessment, Action.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 267–275. MacQueen, Graeme. 2008. “Setting the Role of the Health Sector in Context: MultiTrack Peacework.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 21–25. MacQueen, Graeme; and Santa Barbara, Joanna. 2008. “Mechanisms of Peace through Health.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 27–45. Martin, Susan F.; Davis, Rochelle; Benton, Grace; and Waliany, Zoya. 2017. “Responsibility Sharing for Refugees in the Middle East and North Africa: Perspectives from Policymakers, Stakeholders, Refugees and Internally Displaced Persons.” Report 2017:8. Stockholm: Delmi, The Migration Studies Delegation. Martin, Susan F.; and Zetter, Roger. 2012. “Forced Migration: The Dynamics of Displacement and Response.” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 13–46. Mavroudi, Elizabeth; and Nagel, Caroline. 2016. Global Migration: Patterns, Processes, and Politics. London: Routledge. Mazzetti, Mark; and Almosawa, Shuaib. 2016. “Deadly Hospital Bombing Highlights an Escalating Conflict in Yemen.” New York Times, 25 August, p. A7. McCracken, Kevin; and Phillips, David R. 2017. Global Health: An Introduction to Current and Future Trends. London: Routledge. McMichael, Celia; Barnett, Jon; and McMichael, Anthony J. 2012. “An Ill Wind? Climate Change, Migration, and Health.” Environmental Health Perspectives 120, No. 5 (May):646–654. Mokdad, Ali H.; and dozens of co-authors. 2016. “Health in Times of Uncertainty in the Eastern Mediterranean Region, 1990–2013: A Systematic Analysis for the Global Burden of Disease Study 2013.” Lancet Global Health 4:e704–e713. Montgomery, David; Fernandez, Manny; and Joseph, Yonette. 2017. “At Least 9 Dead in What Police Call a Human Trafficking Crime.” New York Times, 24 July, p. A10. Morgan, Jules. 2016. “Frontline: Providing Health Care in Greece’s Refugee Camps.” Lancet 388 (20 August). Muhumed, Malkhadir M. 2011. “Famine Refugee Camp Has Houses of Sticks, Cloth.” New York Times, 20 August. Ngai, Phyllis Bo-Yuen; and Koehn, Peter H. 2002. Organizational Communication in Refugee-Camp Situations. New Issues in Refugee Research Working Paper No. 71. Geneva: United Nations High Commission for Refugees (UNHCR), December. Ngai, Phyllis Bo-Yuen; and Koehn, Peter H. 2014. “Meeting Diversity in the Midst of Adversity: An Intercultural Communication Training Framework for Refugee-Assistance

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Crisis Management.” In Crisis and Emergency Management: Theory and Practice, edited by Ali Farazmand. Boca Raton, FL: CRC Press. Pp. 13–33. Nossiter, Adam. 2018. “Travelling to Niger to Keep Most Migrants There: France Grants Asylum to a Select Few.” New York Times, 26 February, pp. A1, A6. Ottersen, Ole P.; and 23 co-authors. 2014. “The Political Origins of Health Inequity: Prospects for Change.” Lancet 383 (15 February):630–667. Penttinen, Elina; and Kynsilehto, Anita. 2017. Gender and Mobility: A Critical Introduction. London: Rowman & Littlefield. Porter, Catherine. 2018. “Canada Struggles as It Opens Doors to Victims of ISIS from Iraq.” New York Times, 17 March, pp. A1, A7. Pottie, Kevin; Hui, Chuck; and Schneider, Fabien. 2016. “Women, Children and Men Trapped in Unsafe Corridors.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 291–303. Price-Smith, Andrew T. 2009. Contagion and Chaos: Disease, Ecology, and National Security in the Era of Globalization. Cambridge, MA: MIT Press. Rajabali, Alefiyah; Moin, Omer; Ansari, Amna S.; Khanani, Mohammad R.; and Ali, Syed H. 2009. “Communicable Disease among Displaced Afghans: Refuge without Shelter.” Nature Reviews Microbiology 7 (August):609–614. Renzaho, Andre M.N. 2016a. “Forced Internal Displacement: Pattern, Health Impacts and Policy Response.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 33–71. Rising, David. 2017. “New Trauma Unit to Help Former Islamic State Sex Slaves.” Missoulian, 23 February, p. A8. Rushton, Simon. 2008. “History of Peace through Health.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 15–20. Samers, Michael; and Collyer, Michael. 2017. Migration, 2nd edition. London: Routledge. Santa Barbara, Joanna. 2008a. “Analyzing a Peace through Health Problem.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 119–129. Santa Barbara, Joanna. 2008b. “Dealing with Conflict.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 149–160. Santa Barbara, Joanna; and Arya, Neil. 2008. “Introduction.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 3–13. Schirch, Lisa. 2016. “Civil Society Experiences of, Conflicts with, and Recommendations for Civil-Military Teams.” In Unity of Mission: Civilian-Military Teams in War and Peace, edited by Jon Gundersen and Melanne A. Civic. Maxwell Air Force Base. Alabama: Air University Press. Pp. 297–332. Searcey, Dionne. 2017a. “Endless Rape as War Refuge Turns to Terror.” New York Times, 8 December, p. A1. Searcey, Dionne. 2017b. “Nigerian Warplane Mistakenly Bombs Refugee Camp, Killing Scores.” New York Times, 18 January, p. A4. Sengupta, Somini. 2016. “Record 65 Million People Displaced, U.N. Says.” New York Times, 20 June, p. A3. Sengupta, Somini. 2017. “Despite a U.N. Resolution, Attacks Continue on Medical Personnel in War Zones.” New York Times, 26 May, p. A4. Sengupta, Somini; and Saad, Hwaida. 2017. “Syria’s Young Saw the Worst, But Dangers Lurk beyond ISIS.” New York Times, 1 August, pp. A1, A5.

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Sidel, Victor W.; and Levy, Barry S. 2008. “The Health Effects of War.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 49–66. Solomon, Ben C. 2017. “In Grim Camps, Desperate Scene for Rohingya.” New York Times, 30 September, pp. A1, A11. Solomon Gofie. 2016. “Emigration and Transnational Involvement in the Horn of Africa.” Paper presented at the Annual Meeting of the American Political Science Association, Philadelphia, PA, 1–4 September. Solomon Gofie. 2017. “Politics of Outmigration from the Horn of Africa.” Presentation at The University of Montana, Missoula, Montana, 30 October. Sorensen, Martin S. 2016. “Abuses of Young Refugees in Denmark Mirror Perils across Europe.” New York Times, 20 December, p. A4. Specia, Megan. 2017. “Volunteers on Front Line of Venezuela’s Protests.” New York Times, 14 July, p. A8. Specia, Megan. 2018. “Officials Have Lost Count of How Many Thousands Have Died in Syria’s War.” New York Times, 14 April, p. A9. Specia, Megan; and Boshnaq, Mona. 2017. “Starving and Traumatized, Civilians Emerge from the Ruins of Mosul.” New York Times, 4 July, p. A4. Stoddard, Abby; Fiddyan-Qasmaiyeh, Elena; Long, Katy; and Zetter, Roger. 2012. “Forced Migration and the Humanitarian Challenge: Tackling the Agenda.” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 213–245. Stuckler, David; and Basu, Sanjay. 2013. The Body Economic: Why Austerity Kills. London: Penguin Books. Sugiyama, Satoshi. 2018. “U.N. Sees Rise in Toll of War on Children.” New York Times, 28 June, p. A6. Taub, Amanda. 2017. “Myanmar Follows Global Pattern in How Ethnic Cleansing Begins.” New York Times, 19 September, p. A4. Tavernise, Sabrina. 2016. “Life Expectancy Falls by 5 Years for Syrian Men, Analysis Finds.” New York Times, 25 August, p. A8. Thompson, Nathan A. 2017. “For Rohingya Refugees in Bangladesh, Soccer Is a Joyful Escape.” New York Times, 31 July, p. A9. Toole, Michael. 2006. “Forced Migrants: Refugees and Internally Displaced Persons.” In Social Injustice and Public Health, edited by Barry S. Levy and Victor W. Sidel. Oxford: Oxford University Press. Pp. 190–204. Whitaker, Beth E. 1999. Changing Opportunities: Refugees and Host Communities in Western Tanzania. New Issues in Refugee Research Working Paper No. 71. Geneva: United Nations High Commission for Refugees (UNHCR), June. World Health Organization (WHO). 2010. Health of Migrants: The Way Forward. Report of a Global Consultation Held in Madrid, Spain, 3–5 March. Geneva: World Health Organization. World Health Organization (WHO), Commission on Social Determinants of Health. 2008. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: World Health Organization. Zetter, Roger; and Horst, Cindy. 2012. “Vulnerability and Protection: Reducing Risk and Promoting Security for Forced Migrants.” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 46–79.

3

Health challenges for other survival migrants on the move north Transit conditions and detention centers

Vulnerable “survival migrants” fleeing desperate economic, environmental, and social situations who do not qualify as refugees and are not conflict-displaced constitute the focus of attention in Chapter 3. Roughly one-fifth of all international migration consists of survival and irregular1 migrants, and the numbers are growing (Ottersen, et al., 2014, p. 650). In some circumstances, survival migrants are even more vulnerable to health emergencies and elevated mortality rates than conflict-induced migrants are given the absence of legally binding instruments or political protections covering their displacement and mobility (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 18; Ager and Hermosilla, 2012, pp. 81–84). For instance, Human Rights Watch found that migrant workers who voluntarily enter employment aboard Thai fishing vessels often cannot leave because boat owners, skippers, and brokers hold them in forced labor (Murphy, 2018). We begin this chapter by analyzing the nature of, and social, political, and environmental contributors to, contemporary complex-humanitarian crises. The special mortality and morbidity hazards associated with undocumented and irregular migration, natural ecological catastrophes and industrial accidents, human smuggling, and human trafficking are explored. Then, physical- and mentalhealth conditions in detention centers and the health impact of prolonged detention under substandard living conditions receive attention. The implications for migration health of the legal and moral underpinnings of health as a human right and of humanitarian medicine feature in this discussion. The health challenges associated with Northern immigration-policy contexts are introduced. Crisscrossing treatment of the in-transit health challenges facing survival migrants is analysis of the roles of host governments, UNHCR, the International Organization for Migration (IOM), the Red Cross, MSF, and other NGOs. Chapter 3 concludes with consideration of healthy alternatives to detention.

Complex-humanitarian crises: social, political, and environmental contributors and health and migration impacts Although most people prefer not to abandon their land, homes, and relationships, migration can come to be perceived as a last-resort response to environmental stress and disaster (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 20,

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66–67). Disasters can be understood as exceptionally unfortunate events “that cannot be controlled without outside assistance” (Uscher-Pines, 2009, p. 1).2 In such situations, migration is “often a forced, or even brutal, decision when a disaster leaves no other alternative or where adaptation efforts in the face of environmental degradation have not proved successful” (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 70). Involuntary population movements in the wake of a disaster or emergency can exert even greater negative short-term and long-term impacts on global and personal health than the events themselves; people on the move “not only take with them their own immediate health status but also introduce a new statistical and biological component into the places and populations they join” (McCracken and Phillips, 2017, pp. 310–311, 326). For others, “leaving is not necessarily a solution of last resort, but rather a personal adaptation strategy”; one that even could prove beneficial in the case of climate-change adaptation (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 70–71). Among migrants and non-migrants affected by disasters, physical and virtual “transnationality” behavior occupies “a continuum from low to high or thin to thick, and from very few and short-lived ties to those that are multiple, dense, and continuous over time” (Faist, 2015, p. 195).3 Widespread transnational usage of WhatsApp “demystifies” journeys, provides useful tips, and encourages others to follow in the footsteps of those who go ahead (see Manjoo, 2016, p. B7). Thus, moving involves degrees of coercion and choice, reaction and proaction.4 In many cases, moreover, immobility increases personal and family vulnerability to hazards, stress, and risks of morbidity and mortality (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 28; Salgado de Snyder, et al., 1998; Martin, Weerasinghe, and Taylor, 2014, p. 14).5 Being trapped in immobility “is most often the case for individuals with low socio-economic status, few material and financial assets, or limited social support networks” (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 28–29; also Martin and Zetter, 2012, p. 38). Older and disabled individuals face fewer prospects of exiting and are particularly vulnerable during and after disasters and emergencies (McCracken and Phillips, 2017, pp. 326–327; Chan, 2017, p. 175). Rebuilding the health sector for those who remain after a disaster can take years (Heymann and Chand, 2013, p. 136; Fox and Coto, 2017; McCracken and Phillips, 2017, p. 371). Contributors to migration-inducing disasters Susan Martin, Sanjula Weerasinghe, and Abbie Taylor (2014, p. 5) define a humanitarian crisis as “any situation in which there is a widespread threat to life, physical safety, health or basic subsistence that is beyond the coping capacity of individuals and the communities in which they reside” [emphasis in original]. The immediately apparent generators of complex-humanitarian crises include natural disasters, industrial accidents (e.g., Chan, 2017, p. 37), epidemics and pandemics (Martin, Weerasinghe, and Taylor, 2014, p. 5), and violent acts (Chan, 2017, pp. 36, 38–39). Upstream, and often out of sight, anthropogenic contributors are at work. Policy decisions shaped by unjust economic and political drivers

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degrade environmental, social, and structural features that protect livelihoods and promote health equity (Ottersen, et al., 2014, p. 637; Connell, 2010, p. 24; Duncan, 2014, p. 27). Multinational-corporate influence remains unbridled by the prevailing institutional framework of global governance, including “weak mechanisms for accountability . . . to the people whose lives and health are most directly affected by their actions” (Ottersen, et al., 2014, p. 649). Environmental disasters and the gradual deterioration of vital natural resources commonly drive or contribute to sudden or long-term mass population movements (see Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 36–37; Zetter and Horst, 2012, p. 52). Typhoons (hurricanes), floods (Chan, 2017, p. 97), droughts (Chan, 2017, pp. 102–103, 105–106; McMichael, Barnett, and McMichael, 2012, pp. 648–649),6 earthquakes,7 volcanoes, landslips (Fuller, 2018; Chan, 2017, pp. 95–96), fires, explosions, and immediate or anticipated sea-level rise8 feature as migration-inducing natural and human-provoked (Martin, Weerasinghe, and Taylor, 2014, p. 6) disasters. During the period 2008 through 2014, sudden-onset disasters, mainly weather- or climate-related, displaced some 184 million men, women, and children (Nansen Initiative, 2015, p. 8).9 In 2015 alone, natural disasters uprooted about 24.2 million people.10 African nations and populations have experienced the most incidences of transnational disaster displacement (Nansen Initiative, 2015, p. 15). Upstream and midstream contributors, including weak governance, global economic constraints, hazardous extractive practices, fossil-fuel combustion, armed conflict, poverty, the advertising and marketing of harmful commodities, chronic undernutrition, inadequate health systems, and poor urban planning, “are important factors in disaster displacement as they further weaken resilience and exacerbate the impacts of natural hazards, environmental degradation and climate change” (Nansen Initiative, 2015, p. 16; also Ager and Hermosilla, 2012, p. 81; Koehn, 2007, pp. 1048–1049; Regional Network for Equity in East and Southern Africa, 2017). Public-health impacts The local public-health impacts of natural catastrophes can be severe and lasting (see, for instance, Chan, 2017, pp. 94, 98–100, 149–150, 168; Yoshikawa and Surjan, 2016, p. 109). The 7.0 Richter-scale earthquake that struck Haiti on 12 January 2010, for instance, resulted in “mass casualties, demonstrating how the number, severity, and diversity of injuries can rapidly overwhelm the ability of local medical services” (ibid., p. 67; also see pp. 84–87). In the aftermath of the quake, 30 out of 49 hospitals in the districts primarily affected were damaged or destroyed, 60 percent of the country’s secondary and tertiary health-care facilities were severely damaged, and the sole hospital serving patients with chronic mental illnesses was devastated.11 Haiti’s Ministry of Health was “unable to fulfil its leadership role due the complete destruction of the main administration building” (ibid., pp. 66–67). In addition, unplanned migration in the aftermath of extreme weather events and other natural disasters “has significant public-health implications at its

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origins, along the migration routes and in the receptor areas” (Samet and Zhang, 2014, p. 292). In the immediate wake of rapid-onset disasters, “the most immediate health issues facing displaced populations typically concern access to food, water, and shelter, and adequate sanitation to avoid spread of disease” (Ager and Hermosilla, 2012, p. 81; also Chan, 2017, pp. 92–94). Additional challenging disruptions to health care among dislocated survivors include loss of medical records, termination of relationships with familiar care providers, care avoidance, rupture of support networks, and interruptions in drug treatments (UscherPines, 2009, pp. 2, 17; Dankelman, et al., 2008). Studies suggest that prevailing relocation efforts are not protective of these and other newly encountered risks to physical health12 and often are associated with depression and other mental illnesses13 (Uscher-Pines, 2009, pp. 6, 17; McMichael, Barnett, and McMichael, 2012, pp. 649–650; Carballo, Smith, and Pettersson, 2008, p. 33). In the face of disastrous events, the “inability of the most vulnerable people to migrate” (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 37) also needs to be considered. In some cases, such as the impact of Hurricane Maria on the island of Puerto Rico, vulnerable people are trapped for long periods of time in rapidly deteriorating conditions (Box 3.1; Robles and Ferre-Sadurni, 2017).

Box 3.1 Health care in Puerto Rico in the aftermath of Hurricane Maria Maria knocked out electricity to the entire island, and [five days later] only a handful of Puerto Rico’s 63 hospitals had generators operating at full power. Even those started to falter amid a shortage of diesel to fuel them and a complete breakdown in the distribution network. . . . Only one of the [Doctors’ Center] hospital’s four surgery rooms is operating because the others were contaminated when they were used as shelters after Maria ripped off the roof on the fifth floor and blew out the windows on the fourth. . . . The health system in the U.S. territory was already precarious, with a population that is generally sicker, older, and poorer than that of the mainland, long waits and a severe shortage of specialists as a result of a decade-long economic recession. The island of 3.4 million people has higher rates of HIV, asthma, diabetes, and some types of cancer, as well as tropical diseases such as the mosquito-borne Zika and dengue viruses. Source: Fox and Coto (2017)

Nearly three weeks later, 40 percent of Puerto Rico still lacked running water due to the power failure that continued to hold 85 percent of the island in its grip and “many sick people across the island remained in mortal peril” (Robles, 2017).14 The prolonged loss of electricity and water also precipitated a mental-health crisis

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on the island (Dickerson, 2017). Some of the island’s more fortunate residents, including those with medical conditions for which treatment was impeded by the storm, fled to the U.S. mainland with various intentions about return (Healy and Ferre-Sadurni, 2017). Following floods, many houses remain standing, although they are uninhabitable, resulting in additional disorientation and mental-health challenges (Carey, 2017). Twelve years after Hurricane Katrina, young survivors interviewed in New Orleans agreed that “overcoming the strain of displacement is like escaping the rising water itself – a matter of finding something to hold on to, one safe place or reliable person, each time you move” (Carey, 2017, p. D1; also see Uscher-Pines, 2009, p. 17; Chan, 2017, pp. 72–73). In the wake of climate change, humankind can expect to experience the consequences of extreme weather events of increased intensity and frequency. Rising sea levels are linked to fossil-fuel burning and prospects for collapse of Antarctica’s ice sheets in the face of continued global warming. One recent study of the West and East Antarctica ice sheets warns that “the sea level could rise as much as six feet by the end of this century,” with catastrophic consequences for people, property, and buildings situated within a few feet of sea level. In a worst-case scenario, “a rapid deterioration of Antarctica might . . . cause the sea to rise so fast that tens of millions of coastal refugees would have to flee inland, potentially straining societies to the breaking point” (Gillis, 2017; also see Chapter 7). China suggests a case in point. Rising sea levels and saltwater intrusion present serious intergenerational problems for China’s densely populated coastal cities (Li, 2013). As a result of subsidence in Shanghai, for instance, “the ground level in the city centre is now more than half a meter below sea level” (Cumming and Layne, 2013, p. 232). The interconnected and costly threats posed by sealevel rise include inundation, property and infrastructure destruction, population dislocation, obstructed drainage, vector spread, water-borne diseases, decreased availability of freshwater, and disrupted transportation (Young, 2013; UNHSP, 2011). According to former U.S. Energy Secretary Stephen Chu, sea-level rise would displace greater numbers of people in China than in any other country, including Bangladesh (Bradsher, 2009). Large-scale dam construction and other state-initiated projects, often carried out with international financing, are responsible for another principal contributor to population displacement and adverse health impacts around the world (Cernea, 1997, pp. 1569–1570, 1573; Renzaho, 2016, p. 35; Ferris, 2012, pp. 148, 151, 155–156, 158, 160–163). In its heyday, dam building displaced at least 15 million persons per year (Ferris, 2012, p. 155). Indigenous peoples have been especially vulnerable to displacement for dams and to other means of land grabbing (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 56–57; Ferris, 2012, pp. 148, 163–164). Without social-science insights and local consultation and participation, “development”-excused displacement increases risks of landlessness, unemployment, marginalization, impoverishment, food insecurity, social fragmentation, and morbidity, consequences that are particularly adversely to impact the rural poor and women (see Cernea, 1997, pp. 1573–1576; Bebbington,

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2006, p. 71; Ferris, 2012, pp. 145, 156, 165; Stoddard, et al., 2012, pp. 219–220; Somayaji and Talwar, 2011, pp. 8–9; Chan, 2017, p. 173). And, even in those instances when governments plan resettlement schemes, “affected communities are almost always worse off as a result of displacement” (Ferris, 2012, p. 145). According to Dina Ionesco, Daria Mokhnacheva, and Francois Gemenne, “industrial accidents cause considerable, brutal, and often irreversible environmental degradation, and lead to a level of displacement comparable to that caused by natural disasters.” Unlike the latter, however, “it is impossible pre-emptively [to] evacuate populations, . . . so that at the moment when evacuation can begin, a large number of victims have already been poisoned or contaminated” (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 54–55). Authorities evacuated more than 200,000 residents following the tsunami-generated 2011 Fukushima nuclear accident, “the majority of whom either will not be able or want to return to their homes” located in places where decontamination is incomplete and social and sanitary services remain in disarray (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 54, 24). A range of health concerns, led by fear of cancer from radiation exposure, complicated decision making among Fukushima evacuees (Markus, 2012). Mass South-North survival migrations Extreme global inequalities in the distribution of wealth fuel today’s SouthNorth survival migrations. Forty years after Ali Mazrui (1975, p. 126; also see Papademetriou, 1984, p. 415) propounded his provocative and prescient thesis of “demographic counter-penetration,” unarmed “invasions” by desperate and poor Southern migrants have become a daily global reality. Desperation in the face of unrelenting economic hardship and diminishing survival prospects (see Chapter 5) interacts with other conditions to prod North-South population movements. In recognition of this push factor, Spain’s Secretary of State for Security, José Antonio Nieto, “wants the EU to help develop countries where migrants come from, so they will stop seeking a ‘European miracle’ and stop crossing borders illegally” (Kerr, 2018). Increasingly, moreover, societal disruption fostered by natural disasters, environmental destruction, and upstream economic and political forces play into the hands of unscrupulous human traffickers who are bent on exploiting vulnerable and desperate individuals (Penttinen and Kynsilehto, 2017, pp. 124–125, 129, 139).

Mortality and morbidity hazards faced by vulnerable people on the move Southern populations increasingly “are exposed to a range of vulnerabilities – livelihoods, health, nutritional status, environmental, and shelter conditions – and they move in and out of acute and chronic vulnerability dependent on their respective coping capabilities” (Zetter and Horst, 2012, p. 55; also see Chapter 5). Although vulnerability is multidimensional, we are particularly concerned in this

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rarely make it to rich countries. Most African migrants tend to settle in other African countries. More than half of all refugees are being hosted in Africa and the Middle East. In contrast, the relatively low numbers of people crossing the Mediterranean daily, at great peril, have generated fear and responses that belie European claims of solidarity and respect for international law. In a post-9/11 world, security concerns override any concern for human rights. The erosion of fundamental post-World War values and the global political progression of nationalism has  directly contributed to the ‘othering’ of refugees and asylum-seekers. As per Article 14.1. of the Universal Declaration of Human Rights ‘everyone has the right to seek and to enjoy in other countries asylum from persecution.’ However, by invoking security, Europe, the United States, and other developed nations are characterising migration and those seeking asylum as existentialist threats to their ‘way of life.’ Europe’s deals with Turkey and Libya that seek to externalize European borders have further exacerbated the vulnerabilities of asylumseekers. These policies have greatly dehumanized migrants and criminalized migration to the point where even rescue efforts are now viewed as illegal. We now live in a highly unequal world and our citizenship at birth further exacerbates inequality. In the era of globalisation, it is capital and not labour that is mobile. One-sided trade deals and global warming aid the flow of financial and human capital out of poor countries, creating deep imbalances in power. As a result, states with little control over economy and resources are unable to guarantee security and essential services to their citizens. Human insecurity fuels migration, further hastening the out-flow of resources. With the economy and information operating at a trans-national scale, it is not surprising then that migration levels have picked up pace in the last quarter-century and are unlikely to abate soon. Insecurity, in particular health insecurity, is an important push factor for migration. War is being waged with impunity as attacks against health structures and workers barely register outrage. Destruction of remaining essential services is a deliberate strategy aimed at emptying neighbourhoods and decimating resistance. Shockingly, four out of five permanent members of the UN Security Council have been part of coalitions that have bombed health facilities in the past years. Migrants remain vulnerable through the full-arc of their migratory experiences. Political and humanitarian efforts to meet migrant health needs have often fallen short, be it in refugee camps, transit centres, or in countries of asylum. Even when adequate political will and resources are mustered, considerable social, cultural, and logistical barriers remain. Meeting migrant health needs can be a challenge in well-resourced countries, let alone in countries where essential infrastructure is lacking. At times, migrant-health needs are cited as a reason for denying entry to those seeking asylum. By framing health as a security rather than a humanitarian concern, popular sentiments against immigration are reinforced. Following the 2014 Ebola outbreak in West Africa, travel restrictions that sought to limit travelers from affected countries were not all that successful. Passengers resorted to antipyretic drugs to suppress fever so as to escape detection at airports. In the

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improve operational coordination in humanitarian-relief situations by assigning leading agencies to 11 specific sectors that report to the United Nations Emergency Relief Coordinator (Chan, 2017, pp. 184–185). Transit and destination conditions Paradoxically, populations dislocated by disasters and environmental degradation can face increasing levels of health risk in crowded cities and camps. Assumed to be carriers of infectious diseases, irregular migrants who have not been subjected to health checks prior to entry often are forced to endure deleterious conditions that worsen health conditions and prolong individual vulnerability (Davies, 2010, p. 90). Under camp and settlement conditions characterized by crowding, poor sanitation, and unprotected sources of water, diseases such as cholera, dengue fever, and measles “can reach epidemic proportions very quickly, as occurred in Zimbabwe in 2008–9” (ibid., p. 134; also Chan, 2017, pp. 150–151). Even the presence of negligent earthquake responders can severely damage the health of local populations, as the case of U.N. peacekeepers arriving from Nepal who failed to follow protocols for disposing wastewater in Haiti demonstrates: After six years and 10,000 deaths, the United Nations issued a carefully worded public apology . . . for its role in the 2010 cholera outbreak in Haiti and the widespread [endemic] suffering it has caused since then. (Sengupta, 2016b; also McCracken and Phillips, 2017, p. 371) Migrant-health vulnerabilities are exacerbated by unplanned rapid urbanization. Impoverished migrants are particularly at risk “as they tend to settle in poorly serviced, hazard-prone informal settlements on the periphery of cities” (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 78–81; also see Chan, 2017, p. 190). Often, migrant populations in such informal peripheral settlements are exposed to landslides, floods, or other hazards (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 81). When the option to migrate is not available to all (particularly women and children), on the other hand, departures can result in additional negative consequences for those left behind (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 79). Both those who move and those who stay are equally entitled to the right to health as specified in Article 25 of the Universal Declaration of Human Rights along with access to humanitarian medicine (see Gunn, 2010, pp. 164–165). Strengthened primary-care infrastructure and systems enhances indigenous capacity to meet preventative, immediate post-disaster, and chronic-health needs (Chan, 2017, pp. 156, 210). In recognition of the acute vulnerability involved in migration, the International Organization for Migration, in partnership with governmental and non-governmental agencies, works to facilitate access to essential health services for uprooted populations (IOM, 2012, p. 26). Reframing complex-humanitarian emergencies as sustainable-development and resiliencebuilding opportunities for both the displaced and their hosts offers promise as a

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unifying long-term strategic response (Poole, et al., 2012, pp. 201–204; Astier, 2008, p. S9; Chapter 5). Irregular migrants in transit Special mortality and morbidity hazards are associated with undocumented and irregular migration, human smuggling,20 human trafficking, and tortured captiveterrorist suspects. Mobiles in such circumstances “are granted only minimum rights, and have few mechanisms for securing them” (Ottersen, et al., 2014, p. 650; also Haines, 2017, p.  118).21 Chris Lyttleton (2014) reports graphically on the health hazards encountered by migrants on the move who are bereft of money, family, and other social support, marketable skills, and protection from violent acts. With little recourse to alternatives, irregular migrants frequently accept “[exploitative] work and living conditions that pose threats to physical and mental wellbeing” (Lyttleton, 2014, p. 28; also pp. 41, 111–112, 124, 126, 135, 187; also Merchant, 2017). Sexuality and unprotected sexual contacts, both among migrants and with non-mobile hosts, feature in Lyttleton’s syndemics analysis of disadvantaged populations (pp. 29, 109, 138–140, 179–186, 192, 196; also see Penttinen and Kynsilehto, 2017, pp. 41–42). Strict border-enforcement initiatives and efforts to externalize migration controls (see Martin and Zetter, 2012, pp. 30–31) force determined irregular migrants to take on additional dangers and health risks (Pottie, Hui, and Schneider, 2016, pp. 292, 295; WHO, 2010, p. 90; Duncan, 2014, p. 31; Haines, 2017, p. 119). Many of the world’s 50 million or more irregular migrants have paid to cross one or more borders clandestinely via land, sea, or air. Faced with fortified and risky border crossings, vulnerable irregular migrants frequently turn to networks of smugglers for assistance in gaining entry to the North (Martin and Zetter, 2012, pp. 24–26; Mavroudi and Nagel, 2016, p. 164).22 Migrant smuggling “is a growing criminal activity that preys on poverty, and social and political instability” (Pottie, Hui, and Schneider, 2016, pp. 292–293; also Martin and Zetter, 2012, p. 25). During transit, health care rarely is available for arising needs (Pottie, Hui, and Schneider, 2016, p. 294). Women are vulnerable to sexual violence at the hands of smugglers (WHO, 2010, pp. 90–91). Frequently encountered health problems include dehydration, due to the lack of access to drinking water during the journey, hypothermia, due to being exposed to the cold outside or on a boat, and musculoskeletal complaints caused by the inability to move in cramped boats or trucks, and being forced to remain in the same position over a long period of time. (Pottie, Hui, and Schneider, 2016, p. 295) Hundreds of undocumented migrants have perished from dehydration, heatstroke, suffocation, or hypothermia crossing the border from Mexico into the U.S. states of Texas, Arizona, California, and New Mexico (Fernandez, 2017).23

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In many cases, “people begin their journeys paying to be smuggled only realizing at the point of exploitation, if at all, that they have fallen victim to human trafficking” (Martin and Zetter, 2012, p. 25; also McCracken and Phillips, 2017, p. 314). Authorities estimated the total number of trafficked persons – including adults and children in forced labor and coerced prostitution – at 12.3 million at the end of 2010 (IOM, 2011, p. 57). In cases of human trafficking, the labor and services of people moved are subject to continued control and exploitation in destination places (Martin and Callaway, 2011, p. 217). Victims of traffickers are lured or trapped into forced labor, military service, domestic servitude, or sexual exploitation (Penttinen and Kynsilehto, 2017, pp. 127–132; Potocky, 2010, pp. 112–113).24 In some documented cases, “traffickers who had taken payment to transport African migrants across the desert for passage to Europe instead sold their human cargo to Libyans, and . . . the Libyan buyers often resold them to others” (Kirkpatrick, 2017). For persons trafficked, “the common denominator is violence. Violence takes place en route to the destination, or it may continue for years, such as in the cases of children trafficked for domestic servitude or farm work” (Penttinen and Kynsilehto, 2017, p. 133; also p. 136). Many victims are “exposed to sexually transmitted diseases, including HIV/AIDS” (Martin and Callaway, 2011, pp. 217, 231). Psychological healing from traumatic trafficking experiences “takes time and often requires the help of a [frequently unavailable] professional therapist” (ibid., 2017, p. 137). Protracted displacement Protracted displacement is particularly perilous. Although they might reside among host populations for multiple years, limited and prejudicial access to health services reflects that “migrants are never quite the same as locals” (Lyttleton, 2014, p. 115). After the immediate response to complex crises by relief organizations such as Médecins Sans Frontières and the Red Cross, access to surgical care becomes problematic (Farmer, et al., 2013, pp. 329–330). Indeed, people experiencing protracted displacement tend to “become increasingly vulnerable with time, as assistance and resources deplete after the completion of the emergency phase of the disaster response” (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 22–23).25 Avoiding this outcome requires early attention to sustainable approaches to complex-humanitarian crises (see Martin and Zetter, 2012, p. 32) along with disaster-risk-reduction efforts aimed at analyzing and managing contributing factors and instituting early-warning mechanisms that will reduce the risk and scale of displacement impacts (ibid., 2012, p. 33). Providing security for persons transnationally displaced by disasters Disaster displacement ranks “among the biggest challenges facing States and the international community in the 21st century” (Nansen Initiative, 2015, p. 15). Historically, displaced people who cross borders in the wake of a disaster

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are afforded little or no protection when they arrive in another country. Resource constraints limit the ability of countries in the South to attend to the health and survival needs of arriving displaced migrants (WHO, 2010, p. 91). The Governments of Norway and Switzerland launched the Nansen Initiative in 2012 for the explicit purpose of addressing “the protection and assistance needs of persons displaced across borders in the context of disasters, including the adverse effects of climate change” (Nansen Initiative, 2015, p. 8; also see Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 109, 115). At a global intergovernmental consultation in Geneva in October 2015, 109 governmental delegations endorsed the Agenda for the Protection of Cross-Border Displaced Persons in the Context of Disasters and Climate Change. Specifically, the preparedness-focused Protection Agenda endorses the voluntary admission and enhanced protection26 of disaster-displaced persons based on “humanitarian considerations and international solidarity with disaster affected countries and communities” and supports effective practices that will reduce disaster displacement risks in countries of origin (Nansen Initiative, 2015, pp. 8, 16–17). To be successful, relocation efforts need to take into account ties to land and other resources, cultural values, and people’s need for sustained-livelihood opportunities, basic services, social networks, equivalent lands, and health-protective housing (Nansen Initiative, 2015, p. 18; Cernea, 1997, p. 1580; McMichael, Barnett, and McMichael, 2012, p. 649). In India, Sakarama Somayaji and Smrithi Talwar (2011, p. 9) found that “restoring incomes permanently lost owing to displacement has proven to be the toughest of several sustainable development challenges associated with rehabilitation and resettlement.” Many migrants treat disaster dislocation as a family crisis that requires creative collective coping responses (see Kaiser, 2014, pp. 183, 191, 193–194, 197–200). Spatially, for instance, “displaced households often survive by placing members inside and outside camps, in villages and cities, and across the global South and North” (Stoddard, et al., 2012, p. 220; also Faist, et al., 2015, p. 195).27 To minimize negative impacts on health and well-being, promising interventions include encouraging disaster-displaced individuals to take advantage of their social networks when making relocation decisions and to select close and safe destinations that are “most culturally similar” to the sending site (Uscher-Pines, 2009, p. 20; also Faist, et al., 2015, p. 196).28 Relocation processes are most likely to result in successful outcomes when undertaken in an integrated and adequately financed manner (Cernea, 1997, p. 1580). Consultation with, and influential participation in health-care planning by, those relocated (particularly women) and by host communities, “with full respect of the rights of affected people” (Nansen Initiative, 2015, p. 18), are additional critical factors (Haysom, Pantuliano, and Davey, 2012, pp. 125–127; also Cernea, 1997, p. 1582; McMichael, Barnett, and McMichael, 2012, pp. 649, 651). It is vital, therefore, that community-based decisions and actions be “grounded in representative systems for consultation and collective decisionmaking” (Stoddard, et al., 2012, p. 221) that are responsive to the voices of their most vulnerable members.

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Survival migrants and detention centers: physicaland mental-health conditions Under the guise of “securitization,” undocumented migrants who reach the North increasingly are being held in detention centers (Sampson, et al., 2015, p. ii; Cyril and Renzaho, 2016, pp. 207–208; Mavroudi and Nagel, 2016, p. 129). Immigration detention, a means of administrative rather than criminal confinement (Sampson and Mitchell, 2013, p. 99), is “an institutionalized extreme form of restricted mobility” that can “last for a long time” (Penttinen and Kynsilehto, 2017, p. 96; also Sampson and Mitchell, 2013, pp. 100–101). In detention, migrant moves are monitored closely. Increasingly, detention facilities around the world are outsourced to private-security companies (Penttinen and Kynsilehto, 2017, p. 96) that value profit making over migrant care (Mavroudi and Nagel, 2016, p. 129). Harsh detention conditions and experiences threaten the health of survival migrants in a number of ways (Pottie, Hui, and Schneider, 2016, p. 296; Cyril and Renzaho, 2016, p. 219; McCracken and Phillips, 2017, p. 314). Therefore, physical- and mental-health conditions in detention centers and the health impact of prolonged detention under substandard living conditions merit serious attention and monitoring (see Cyril and Renzaho, 2016, p. 247).29 In recent years, Greece has served as a popular gateway for survival migrants endeavoring to reach Europe (Cyril and Renzaho, 2016, pp. 210–211). In their case study of detention-policy and practice impacts on migrant health in Greece, Sheila Cyril and Andre Renzaho (2016, pp. 216–217, 220–224; also Garcia-Zamora, 2017, p. 590) found that authorities confined asylum seekers30 and other detainees in “inhumane conditions . . . including overcrowded cells without proper ventilation or sunlight, poor sanitation and low hygiene.” Detained migrants were at high risk of acquiring infectious diseases; substandard conditions, along with physical and emotional abuse, contributed to a majority of the health problems they confronted – including the aggravation of chronic and mental-health conditions. In Greece and elsewhere, however, “NGOs have played a powerful role in improving the conditions in detention facilities” (Cyril and Renzaho, 2016, pp. 246, 239–242).31 MSF, in particular, has provided primary-health care, personal-hygiene kits, treatment of infectious diseases, interpretative and psychological assistance, and other health-related services (ibid., pp. 237–238). Extremely vulnerable lesbian, gay, bisexual, transgender, and intersex individuals are especially prone to experience abuse and lack of access to appropriate medical care during immigration detention (Frew, Fausch, and Cox, 2016, p. 4). LGBTI persons face heightened levels of harassment, discrimination, psychological abuse, physical and sexual violence by detention staff as well as other detainees. They are frequently segregated in conditions falling below those of the general detainee population and well-established international standards, or are

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Health challenges for other survival migrants subjected to policies of solitary confinement, which have been shown to have severe mental- and physical-health consequences. (Frew, Fausch, and Cox, 2016, p. 4)

Many sexual minorities are “traumatized by experiences in detention” (Tabak and Levitan, 2013). Detention facilities also are sites where children are subjected to sexual abuse. For instance, “adult inmates may specifically target children based on their culturally specific beliefs that sexual contact with a child will cure HIV/AIDS infections” (Penttinen and Kynsilehto, 2017, p. 116; Cyril and Renzaho, 2016, pp. 223–224). Moreover, “even very short periods of detention can undermine a child’s psychological and physical wellbeing and compromise their cognitive development” (Sampson, et al., 2015, p. 22). Confinement, isolation from familiar social networks, and receiving-country exclusions generate stresses that adversely affect the health of irregular migrants. Health services typically are of poor quality and the health-care personnel employed by detention facilities lack “training for migrant-related health issues” (Pottie, Hui, and Schneider, 2016, p. 298; also UNHCR, 2014, p. 5; Cyril and Renzaho, 2016, pp. 222, 248). In most cases, moreover, detention is unnecessary. For multiple reasons, including the serious negative physical- and mental-health consequences experienced by detainees (WHO, 2010, p. 50; Puthoopparambil, Ahlberg, and Bjerneld, 2015, pp. 81–82), former U.N Secretary-General Ban Ki-moon declared that “detention is not the answer. It should end immediately” (Sengupta, 2016a). UNHCR advocates an end to the detention of children and the immediate release of any children still confined (UNHCR, 2014, p. 17).32 Healthy alternatives to detention The International Detention Coalition (IDC), a worldwide network of more than 300 NGOs from some 70 countries (Cyril and Renzaho, 2016, p. 236), is committed to realizing Secretary-General Ban Ki-moon’s charge. IDC’s position is that “vulnerable individuals should never be placed in immigration detention” (Frew, Fausch, and Cox, 2016, p. 4). The Coalition has documented the numerous benefits of alternatives to administrative detention (Sampson, et al., 2015, pp. iii–iv; also Pottie, Hui, and Schneider, 2016, p. 298). In all situations, IDC holds that immigration detention should be “used as a last resort in exceptional cases” (Sampson, et al., p. ii; also pp. 71–74). UNHCR shares this position (Sampson and Mitchell, 2013, p. 105). Hygienic conditions, adequate health services, and safety and security are essential to ensure that irregular migrants secure their right to health (WHO, 2010, p. 51). These core principals provide the framework for considering healthy alternatives to detention, such as the IDC’s Revised Community Assessment and Placement (RCAP) model. The IDC’s alternative approach is based upon the premise that migrants must be treated “as rights holders who can be empowered to comply with immigration processes without the need for restrictions or deprivations of liberty” (Sampson, et al., 2015, p. ii).

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RCAP is based on “individualised assessment of the migrant followed by community [context] assessment and application of conditions in the community if required” (Pottie, Hui, and Schneider, 2016, p. 298; also Sampson and Mitchell, 2013, p. 110). RCAP employs individualized case management across all stages that “builds on an individual’s strengths, identifies vulnerability or protection concerns, and addresses needs. . . . The approach promotes coping and wellbeing by facilitating access to support services and networks” (Sampson, et al., 2015, p. vi). While awaiting the outcome of migration procedures, community placements can be unconditional or “with such conditions as determined to be necessary and proportionate in the individual case” (ibid., p. vii). Migrants placed without conditions are still expected to be “responsible for ensuring their good status and active participation in the applicable migration procedure” (ibid., p. vii; also pp. 59–61). In individually tailored cases where serious concerns preclude unconditional placement in the community, “necessary, reasonable, and proportional” conditions include “directed residence” and “monitoring, supervision, surety, and other consequences for noncompliance” (ibid., p. viii; also pp. 65–71; Cyril and Renzaho, 2016, pp. 231–232). In place of administrative detention, IDC maintains, for instance, that states should work closely with LGBTI leaders and grassroots organisations to support and protect LGBTI persons in the community while their immigration status is being resolved. LGBTI-sensitive alternatives to detention should include community placement and support services uniquely designed to meet the needs of LGBTI persons. (Frew, Fausch, and Cox, 2016, p. 4)

Health care challenges for survival migrants in Northern receiving contexts This chapter has demonstrated how disasters can introduce unexpected levels of morbidity and mortality, overwhelm and destroy local health systems, provoke mass dislocation and population movement, and adversely affect physical and mental health in the long run. We also encountered promising approaches for addressing these conditions. Globally, awareness is growing regarding the importance of integrating health considerations in disaster-risk-reduction strategies. The landmark Sendai Framework for Disaster Risk Reduction 2015–2030, adopted by U.N. member states, prioritizes “resilience building within the international community, creating a 15-year roadmap to enable countries to reduce disaster risk, and losses in lives, livelihoods, and health” (Lo, Chan, and Chan, 2017). The next step is to elaborate and extend the Sendai Framework principles and to develop means of assuring their implementation on behalf of persons who survive disasters in place or as dislocated movers. Survival migrants include the thousands of new arrivals who camp out for weeks or months in the streets of Northern cities like Paris (Penttinen and Kynsilehto, 2017, p. 143). Like their hosts, survival migrants who succeed in reaching

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the North will be better positioned to weather future health-impacting crises if their communities develop robust social networks and “collective efficacy,” or “willingness to intervene on behalf of the common good” (Sampson, 2013). Restoring disrupted continuity of health care and psychological well-being (Ager and Hermosilla, 2012, pp. 86–87)33 rank among the most challenging issues that confront Northern providers who see transnationally dislocated persons in the aftermath of complex-humanitarian crises. Chapter 4 takes up these and related challenges.

Notes 1 “Irregular” migrants do not possess “legal status in a transit or host country” (Ottersen, et al., 2014, p. 649). 2 For United Nations Office for Disaster Risk Reduction (UNISDR), WHO, and Centre for Research on the Epidemiology of Disasters (CRED) definitions and categorizations, see Chan (2017, pp. 27, 33–34). 3 Also see Katharina Manderscheid’s (2009, p. 35) discussion of unequal networking capacity for transnational mobility and Timo Ohnmacht, Hanja Maksim, and Manfred Bergman’s (2009, p. 12) three central aspects of “motility” competence. 4 For an excellent visualization of migration tendencies that incorporates duration (short term to long term), level of coercion (forced to voluntary), and level of preparedness (proactive to reactive), see Ionesco, Mokhnacheva, and Gemenne (2017, p. 3). 5 For an alternative perspective that emphasizes empowering outcomes for wives left behind in rural Tanzania, see Archambault (2010). 6 Prolonged and recurrent drought “undermines livelihoods and is a principal cause of displacement for millions who reply on subsistence agriculture and pastoralism in substantial parts of East and West Africa” (Martin and Zetter, 2012, p. 24; also Chan, 2017, p. 103). When drought conditions reinforce “conflict or other political factors, food insecurity may be the factor that forces populations that have exhausted all their coping strategies to migrate or starve” (Martin and Zetter, 2012, p. 24). 7 For instance, the earthquakes that struck Mexico in September 2017 damaged more than 150,000 homes and resulted in mass long-term displacements (Franco and Semple, 2017). 8 See Goodell (2017, p. 178). He reports that “Globally, more than one billion people live in what demographers call low-elevation coastal zones. A fair percentage of these people are in poor countries with little money to help with adaptation.” Jeff Goodell then asks, “As the waters rise, where will they go?” 9 At least half a million houses were completely destroyed and more than four million people displaced when Typhoon Haiyan struck the Philippines in 2013 (Chan, 2017, p. 92). 10 “PDD Fact Sheet” at disasterdisplacement.org/wp-content/uploads/2015/03/17072017_ PDD_Fact-Sheet.pdf; accessed 21 October 2017; also see Sengupta (2016a). 11 In contrast, “over 90% of primary health care centres remained intact or suffered only light damage” (Chan, 2017, p. 66). 12 Lori Uscher-Pines’ (2009, pp. 2, 5) literature search found that concern with physical health often is tangential in post-disaster relocation studies. Further, “although disasters in the developing world are the most deadly and disruptive, they make up a minority of the studied disasters” (p. 18). 13 For a multi-layer approach to addressing diverse mental-health and psychosocialsupport needs in post-disaster situations, see Chan (2017, pp. 160–162).

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14 Two months after Hurricane Maria, a University of Washington team led by a diaspora chemical-engineering professor, creatively installed solar-powered refrigerators that finally enabled a remote mountain community to preserve health-dependent medications (Johnson, 2017). 15 On the frequent post-disaster neglect of chronic diseases, see Chan (2017, pp. 154–156). 16 For instance, Saudi Arabia deported upwards of 150,000 precariously situated Ethiopians in 2013 and 2014 (Solomon, 2016, pp. 7–8). The Government of Israel offered thousands of resident Eritreans and Sudanese money if they moved to Rwanda (and prison if they did not), but the Government of Rwanda eventually refused forced deportation (Gellar, 2017). 17 On the minimum standards required to support population health in the wake of disasters suggested by the Sphere Project, see Chan (2017, pp. 121–124). For specific approaches to addressing the needs of dislocated populations, see ibid. (pp. 133–141). 18 See the list of key international-disaster-response stakeholders found in Chan (2017, pp. 183–184). 19 However, the health-supporting roles of NGOs often are heavily influenced by selfinterest and donor-state pressures (Davies, 2010, p. 133). In addition, humanitarian agencies rarely become involved in providing assistance to persons dislocated by largescale government infrastructure schemes (Ferris, 2012, p. 151). 20 Including the smuggling of unaccompanied children who have parents and/or other relatives already living in the North (see Nixon and Dickerson, 2017). 21 Smugglers placed Rohingya migrants from Bangladesh and Myanmar in bamboo cages and tortured, raped, and buried them in a mass grave in Songkhla Province, Thailand (Jirenuwat and Goldman, 2017; also see Pottie, Hui, and Schneider, 2016, p. 295). 22 Migrant smuggling “includes those who consent to being smuggled” and generally is a one-time action that ends once the smuggled person has reached the destination country and completed payment for the service (Potocky, 2010, p. 113). 23 In Southern Somalia, thugs have “charged weary famine victims a ‘shade tax’ to rest along the road under ‘their’ trees” (Gettleman, 2017, p. 289). 24 Nearly three-fourths of the victims of human trafficking are women and children, according to a 2016 U.N. Office on Drugs and Crime (UNODC) report (Missoulian, 22 December 2016, p. A7). 25 Also see the video Living in Emergency, which documents the exit dilemmas that face Médecins Sans Frontières staff. 26 Under the Protection Agenda, “protection” refers to any positive actions by states on behalf of disaster-displaced persons “that aim at obtaining full respect for the rights of the individual in accordance with the letter and spirit of applicable bodies of law, namely human rights law, international humanitarian law and refugee law” (Nansen Initiative, 2015, p. 17). 27 On migration-decision making as a family investment strategy and safety valve, see Connell (2014, pp. 74, 76, 79–80). 28 An interesting example of the use of migration policy to ameliorate severe dislocation consequences is the U.S. government’s 2012 decision to “allow Haitians to apply for temporary work visas as a means of encouraging remittance flows for post-earthquake reconstruction” (Stoddard, et al., 2012, p. 225). In contrast, returned Mexicans, whose remittance-build homes in San Francisco Xochiteopan from years of unauthorized work in the United States were severely damaged or destroyed by the 2017 earthquake, were despondent about prospects under the Trump administration for the further flow of remittances needed for rebuilding their poor rural village. One former migrant, who toiled for three years in New Jersey restaurant kitchens and a carwash, lamented, “You work years there, and in three, four seconds it’s all over.” Another returned migrant

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31 32 33

Health challenges for other survival migrants was overcome by emotion contemplating “the migration, the hardships in New York, the earthquake, [and] the uncertain road ahead for his small village” (Semple, 2017). On monitoring needs, types, and best practices, see Vanderbruggen, Vlaanderen, and Stevens (2015). Only a small percentage of asylum seekers who can prove personal persecution are granted asylum by Northern governments and obtain official immigrant status. The others linger in legal limbo or are allowed to remain in irregular status (Mavroudi and Nagel, 2016, pp. 136–137; Magra, 2018; Koehn, 1991, pp. 209–214, 235–237). Monitoring detention places also is “an essential activity and part of UNHCR’s supervisory responsibility” (UNHCR, 2014, p. 12). In 2011, Japan released all migrant children from detention centers and acted to preclude child detention in the future (Sampson and Mitchell, 2013, p. 103). Common types of individual psychological issues that arise following disasters include acute stress disorder (within two days and four weeks), generalized anxiety disorder (lasting over six months), major depressive disorder (persisting at least two weeks), and post-traumatic stress disorder (presenting with symptoms for longer than one month) (Chan, 2017, p. 158).

References Ager, Alastair; and Hermosilla, Sabrina. 2012. “Health on the Move: The Impact of Forced Displacement on Health.” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 81–110. Archambault, Caroline. 2010. “Women Left Behind? Migration, Spousal Separation, and the Autonomy of Rural Women in Ugweno, Tanzania.” Signs: Journal of Women in Culture and Society 35:919–942. Astier M. Almedom. 2008. “Resilience Research and Policy/Practice Discourse in Health, Social, Behavioral, and Environmental Sciences over the Last Ten Years.” African Health Sciences 8 (December):S1–S13. Bebbington, Anthony. 2006. “Michael Cernea.” In Fifty Key Thinkers on Development, edited by David Simon. London: Routledge. Pp. 67–73. Bradsher, Keith. 2009. “American Officials Press China on Efforts to Curb Greenhouse Gases.” New York Times, 16 July, p. A10. Carballo, Manuel; Smith, Chelsea B.; and Pettersson, Karen. 2008. “Health Challenges.” Forced Migration Review 31 (October):32–33. Carey, Benedict. 2017. “Katrina and Its Hard-Learned Lessons.” New York Times, 12 September, pp. D1, D6. Cernea, Michael. 1997. “The Risks and Reconstruction Model for Resettling Displaced Populations.” World Development 25 (10):1569–1587. Chan, Emily Ying Yang. 2017. Public Health Humanitarian Responses to Natural Disasters. London: Routledge. Connell, John. 2010. Migration and the Globalisation of Health Care: The Health Worker Exodus? Cheltenham, UK: Edward Elgar. Connell, John. 2014. “The Two Cultures of Health Worker Migration: A Pacific Perspective.” Social Science and Medicine 116:73–81. Cumming, Ayden; and Layne, Davina. 2013. “Shanghai, China.” In Megacities and the Coast: Risk, Resilience and Transformation, edited by Mark Pelling and Sophie Blackburn. London: Routledge. Pp. 231–235. Cumming-Bruce, Nick. 2016. “Deadliest Year for Migrants Crossing the Mediterranean.” New York Times, 24 December, p. A3.

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Cyril, Sheila; and Renzaho, Andre M.N. 2016. “Invisible and Suffering: Prolonged and Systematic Detention of Asylum Seekers Living in Substandard Conditions in Greece.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 207–254. Dankelman, Irene; Alam, Khurshid; Ahmed, Wahida B.; Gueye, Yacine D.; Fatenia, Naureen; and Mensah-Kutin, Rose. 2008. “What It Means for Women.” Forced Migration Review 31 (October):56. Davies, Sara. 2010. Global Politics of Health. Cambridge, UK: Polity Press. Dickerson, Caitlin. 2017. “After the Storm, a Mental Health Tempest.” New York Times, 14 November, p. A15. Duncan, Whitney L. 2014. “Transnational Disorders: Returned Migrants at Oaxaca’s Psychiatric Hospital.” Medical Anthropology Quarterly 29 (1):24–41. Faist, Thomas; Bilecen, Basak; Barglowski, Karolina; and Sienkiewicz, Joanna J. 2015. “Transnational Social Protection: Migrants’ Strategies and Patterns of Inequalities.” Population, Space and Place 21:193–202. Farmer, Paul; Basilico, Matthew; Kerry, Vanessa; Ballard, Madeleine; Becker, Anne; Bukhman, Gene; Dahl, Ophelia; Ellner, Andy; Ivers, Louise; Jones, David; Meara, John; Mukherjee, Joia; Sievers, Amy; and Yamamoto, Alyssa. 2013. “Global Health Priorities for the Early Twenty-First Century.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 302–339. Fernandez, Manny. 2017. “A Northbound Path, Marked by More and More Bodies.” New York Times, 5 May, pp. A1, A22–A23. Ferris, Elizabeth. 2012. “Development and Displacement: Hidden Losers from a Forgotten Agenda.” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 145–173. Fox, Ben; and Coto, Danica. 2017. “Hurricane Stresses Puerto Rico’s Already Weak Health System.” Missoulian, 1 October, p. A6. Franco, Marina; and Semple, Kirk. 2017. “After 2 Quakes in Mexico This Month, Legions of Displaced Are Still Reeling.” New York Times, 28 September, p. A6. Frew, Amy; Fausch, Aline; and Cox, Kaleb. 2016. LGBTI Persons in Immigration Detention. Victoria, Australia: International Detention Coalition. Fuller, Thomas. 2018. “Mudslides Leave behind Winding Scar of Debris: Death Toll Climbs to 17.” New York Times, 11 January, p. A18. Garcia-Zamora, Jean-Claude. 2017. “The Global Wave of Refugees and Migrants: Complex Challenges for European Policy Makers.” Public Organization Review 17:581–594. Gellar, Sheldon. 2017. “Rwanda Says No to Migrant Deportation.” Jerusalem Post, 2 December. Gettleman, Jeffrey. 2017. Love, Africa: A Memoir of Romance, War, and Survival. New York: HarperCollins. Gillis, Justin. 2017. “Antarctic Dispatches,” New York Times, 20 May, pp. A11–A12. Goodell, Jeff. 2017. The Water Will Come: Rising Seas, Sinking Cities, and the Remaking of the Civilized World. New York: Little, Brown. Grondin, Danielle; Weekers, Jacqueline; Haour-Knipe, Mary; Elton, Akram; and Stukey, Julia. 2003. “Health-An Essential Aspect of Migration Management.” In World Migration 2003: Managing Migration Challenges and Responses for People on the Move, edited by Thomas L. Weiss. Geneva: International Organization for Migration. Pp. 85–93. Gunn, S. William A. 2010. “The Humanitarian Imperative in Major Health Crises and Disasters.” In Understanding the Global Dimensions of Health, edited by S.W.A. Gunn. New York: Springer. Pp. 159–168.

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Gushulak, Brian. 2001. “Health Determinants in Migrants: The Impact of Population Mobility on Health.” In Health, Migration and Return: A Handbook for a Multidisciplinary Approach, edited by Peter J. van Krieken. The Hague: T.M.C. Asser Press. Pp. 255–268. Haines, David W. 2017. Immigration Structures and Immigrant Lives: An Introduction to the US Experience. Lanham, MD: Rowman & Littlefield. Haysom, Simone; Pantuliano, Sara; and Davey, Eleanor. 2012. “Forced Migration in an Urban Context: Relocating the Humanitarian Agenda.” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 113–143. Healy, Jack; and Ferre-Sadurni, Luis. 2017. “Where the Most Coveted Item Is a Plane Ticket Out.” New York Times, 6 October, p. A14. Heymann, David L.; and Chand, Sudeep. 2013. “Diplomacy and Global Health Security.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 125–139. International Organization for Migration [IOM]. 2011. World Migration Report 2011: Communicating Effectively about Migration. Geneva: International Organization for Migration. International Organization for Migration [IOM]. 2012. Report of the Director General on the Work of the Organization for the Year 2011. MC/2346. Geneva: International Organization for Migration, 1 June 2012. Ionesco, Dina; Mokhnacheva, Daria; and Gemenne, Francois. 2017. The Atlas of Environmental Migration. London: Routledge. Jirenuwat, Ryn; and Goldman, Russell. 2017. “Dozens Found Guilty in Thailand in Human-Trafficking Case.” New York Times, 2 July, p. A5. Johnson, Kirk. 2017. “Politics and Disasters Provide Fresh Incentive for Energy Innovations.” New York Times, 12 December, p. A17. Jordan, Miriam. 2017. “Wildfires May Also Destroy Wine Country’s Work Force.” New York Times, 18 October, p. A16. Kaiser, Tania. 2014. “Crisis? Which Crisis? Families and Forced Migration.” In Crisis and Migration: Critical Perspectives, edited by Anna Lindley. London: Routledge. Pp. 181–202. Kerr, Chloe. 2018. “Spain Blasts EU for Wasting Money Trying to Stop Migrants ‘Waiting for European Miracle’.” Express, 12 February. Kirkpatrick, David D. 2017. “Europe Wanted Migrants Stopped: Now Some Are Sold as Slaves.” New York Times, 1 December, p. A9. Koehn, Peter H. 1991. Refugees from Revolution: U.S. Policy and Third-World Migration. Boulder, CO: Westview Press. Koehn, Peter H. 2007. “Global Health and Human Rights: Challenges for Public-Health Administrators in an Era of Interdependence and Mobility.” In Handbook of Globalization, Governance, and Public Administration, edited by Ali Farazmand and Jack Pinkowski. Boca Raton, FL: CRC Press. Pp. 1045–1073. Li, Jian. 2013. “China and Climate Change: Environmental Impacts, Human Security, and Migration Policies and Actions.” In Climate Change, Sustainable Development, and Human Security: A Comparative Analysis, edited by Dhirendra K. Vajpeyi. Lanham, MD: Lexington Books. Pp. 111–138. Lo, Sharon Tsoon Ting; Chan, Gloria Kwong Wai; and Chan, Emily Ying Yang. 2017. “An Example of How ‘Health’ Might Be Integrated into International Policy Frameworks: The Sendai Framework for Disaster Risk Reduction 2015–2030, Bangkok Principles (March 2016) and New Delhi Declaration (November 2016).” In Public Health

xviii Acronyms and abbreviations GVF HIV HIVAN HMI ICRC ICT IDC IDHA IDPs IDRC IFRC IHRs IMF IOM IPCC IUPUI JCI LAMS LEADS LGBTI LMICs MDGs MEPI mHealth MPH MSF NCD NGO North NTDs NWFP OECD PDD PM PM2.5 PM10 ProMED or ProMED-mail PTSD RCAP

global viral forecasting human immunodeficiency virus Centre for HIV/AIDS Networking Harvard Medical International International Committee of the Red Cross information and communications technology International Detention Coalition International Diploma in Humanitarian Assistance internally displaced persons International Development Research Centre International Federation of Red Cross and Red Crescent Societies International Health Regulations International Monetary Fund International Organization for Migration Intergovernmental Panel on Climate Change Indiana University-Purdue University, Indianapolis Joint Commission International of the Joint Commission on the Accreditation of Health Care Organizations Latin American Medical School Linkage with Experts and Academics in the Diaspora Scheme (Nigeria) lesbian, gay, bisexual, transgender, and intersex persons low and middle-income countries Millennium Development Goals Medical Education Partnership Initiative mobile health through text messaging Masters of Public Health Médecins Sans Frontières (Doctors Without Borders) non-communicable disease non-governmental organization Global North neglected tropical diseases North-west Frontier Province (Pakistan) Organization for Economic Co-operation and Development pervasive developmental disorder particulate matter fine inhalable particles, with diameters that are generally 2.5 micrometers and smaller inhalable particles, with diameters that are generally 10 micrometers and smaller Program for Monitoring Emerging Diseases post-traumatic stress disorder Revised Community Assessment and Placement model

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Kosoko-Lasaki, Cynthia T. Cook, and Richard L. O’Brien. Sudbury, MA: Jones and Bartlett Publishers. Pp. 1–35. Papademetriou, Demetrios G. 1984. “International Migration in a Changing World.” International Social Science Journal 36 (3):409–423. Penttinen, Elina; and Kynsilehto, Anita. 2017. Gender and Mobility: A Critical Introduction. London: Rowman & Littlefield. Poole, Lydia; Willitts-King, Barnaby; Hammond, Laura; and Zetter, Roger. 2012. “Who Pays? Who Profits? The Costs and Impacts of Forced Migration.” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 175–211. Potocky, Miriam. 2010. “Social Work Practice with Victims of Transnational Human Trafficking.” In Transnational Social Work Practice, edited by Nalini J. Negi and Rich Furman. New York: Columbia University Press. Pp. 111–123. Pottie, Kevin; Hui, Chuck; and Schneider, Fabien. 2016. “Women, Children and Men Trapped in Unsafe Corridors.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 291–303. Puthoopparambil, Soorei J.; Ahlberg, Beth M.; and Bjerneld, Magdalena. 2015. “‘A Prison with Extra Favors’: Experiences of Immigrants in Swedish Detention Centres.” International Journal of Migration, Health and Social Care 11 (2):73–85. Regional Network for Equity in Health in East and Southern Africa (EQUINET). 2017. “Resource Curse or Fair Benefit? Protecting Health in the Extractive Sector in East and Southern Africa.” Civil Society Brief, November. www.equinetafrica.org/ Renzaho, Andre M.N. 2016. “Forced Internal Displacement: Pattern, Health Impacts and Policy Response.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 33–71. Robles, Frances. 2017. “Medical Crisis in Puerto Rico: ‘The Whole Island Is Critical’.” New York Times, 11 October, pp. A1, A13. Robles, Frances; and Ferre-Sadurni, Luis. 2017. “Hurricane’s Impact: ‘There Will Be No Food in Puerto Rico’.” New York Times, 25 September, p. A11. Salgado de Snyder, V. Nelley; Diaz-Perez, Ma de Jesus; Maldonado, Margarita; and Bautista, Elida M. 1998. “Pathways to Mental Health Services among Inhabitants of a Mexican Village.” Health and Social Work 23, No. 4 (November):249–261. Samet, Jonathan M.; and Zhang, Junfeng. 2014. “Climate Change and Health.” In Routledge Handbook of Global Public Health in Asia, edited by Sian M. Griffiths, Jin Ling Tang, and Eng Kiong Yeoh. London: Routledge. Pp. 281–298. Sampson, Robert. 2013. “Survival of the Sociable.” NewScientist, 11 May, pp. 28–29. Sampson, Robyn; Chew, Vivienne; Mitchell, Grant; and Bowring, Lucy. 2015. There Are Alternatives: A Handbook for Preventing Unnecessary Immigration Retention, revised edition. Victoria, Australia: International Detention Coalition. Sampson, Robyn; and Mitchell, Grant. 2013. “Global Trends in Immigration Detention and Alternatives to Detention: Practical, Political and Symbolic Rationales.” Journal on Migration and Human Security 1 (3):97–121. Searcey, Dionne; and Barry, Jaime Y. 2017. “Leaving Home, One By One, along ‘Deadliest Route’ to Europe.” New York Times, 23 June, pp. A1, A9. Semple, Kirk. 2017. “A Village ‘Left with Nothing’.” New York Times, 26 September, p. A4. Sengupta, Somini. 2016a. “Record 65 Million People Displaced, U.N. Says.” New York Times, 20 June, p. A3. Sengupta, Somini. 2016b. “U.N. Issues an Apology for Its Role in Haiti’s 2010 Cholera Outbreak.” New York Times, 2 December, p. A12.

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Solomon Gofie. 2016. “Emigration and Transnational Involvement in the Horn of Africa.” Paper presented at the Annual Meeting of the American Political Science Association, Philadelphia, PA, 1–4 September. Somayaji, Sakarama; and Talwar, Smrithi. 2011. “Development-Induced Displacement, Rehabilitation and Resettlement in India: Current Issues and Challenges.” In DevelopmentInduced Displacement, Rehabilitation and Resettlement in India: Current Issues and Challenges, edited by Sakarama Somayaji and Smrithi Talwar. London: Routledge. Pp. 1–10. Stoddard, Abby; Fiddyan-Qasmaiyeh, Elena; Long, Katy; and Zetter, Roger. 2012. “Forced Migration and the Humanitarian Challenge: Tackling the Agenda.” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 213–245. Tabak, Shana; and Levitan, Rachel. 2013. “LGBTI Migrants in Immigration Detention.” Forced Migration Review 42:47–49. United Nations High Commission for Refugees (UNHCR). 2014. Beyond Detention: A Global Strategy to Support Governments to End the Detention of Asylum-Seekers and Refugees, 2014–2019. Geneva: UNHCR. United Nations Human Settlements Programme (UNHSP). 2011. Cities and Climate Change: Global Report on Human Settlements 2011. London: Earthscan Publications. Uscher-Pines, Lori. 2009. “Health Effects of Relocation Following Disaster: A Systematic Review of the Literature.” Disasters 33 (1):1–22. Vanderbruggen, Maaike; Vlaanderen, Vluchtelingenwerk; and Stevens, Jem. 2015. NGO Monitoring of Immigration Detention: Tips, Examples and Positive Practices. Victoria, Australia: International Detention Coalition. World Health Organization (WHO). 2010. Health of Migrants: The Way Forward. Report of a Global Consultation Held in Madrid, Spain, 3–5 March. Geneva: World Health Organization. Yoshikawa, Minako Jen; and Surjan, Akhilesh. 2016. “Human Health as Precondition for Achieving Sustainable Development.” In Disaster Risk Reduction: Methods, Approaches and Practices, edited by Juha I. Uitto and Rajib Shaw. Tokyo: Springer. Pp. 103–117. Young, Andrea F. 2013. “Coastal Megacities, Environmental Hazards and Global Environmental Change.” In Megacities and the Coast: Risk, Resilience and Transformation, edited by Mark Pelling and Sophie Blackburn. London: Routledge. Pp. 70–99. Zetter, Roger; and Horst, Cindy. 2012. “Vulnerability and Protection: Reducing Risk and Promoting Security for Forced Migrants.” In World Disasters Report 2012, edited by Roger Zetter. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC). Pp. 46–79.

Acronyms and abbreviations xix SARS SDGs South STDs TC THEP TOKTEN UNAIDS UNDP UNEP UNHCR UNISDR UNODC WHO

severe acute respiratory syndrome Sustainable Development Goals Global South sexually transmitted diseases transnational competence transnational higher-education partnership Transfer of Knowledge through Expatriate Nationals programme Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Environment Programme United Nations High Commission for Refugees United Nations Office for Disaster Risk Reduction U.N. Office on Drugs and Crime World Health Organization

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(e.g., crowded and substandard housing conditions, separation from family, underemployment, location in settings with high prevalence of HIV) then combine with individual behavioral inclinations (loneliness, boredom, sexual urges, moral values, etc.) to increase contraction prospects (Organista, et al., 2012, pp. 8–11; also Hirsch and Vasquez, 2012, pp. 106, 108, 110–113).

The impact of unequal mobilities Northern countries host a variety of migrants who arrive with unequal status, including legally admitted immigrants, refugees who have completed pre-arrival health checks, persons covered by temporary-protection status, and irregular entrants and asylum seekers who may or may not be confined to asylum or detention centers.2 The health needs of arriving men, women, and children also vary. For instance, refugees and conflict-induced migrants can arrive with “physical and psychological trauma and stress-related disorders” along with infectious and parasitic diseases (Palinkas, et al., 2003, p. 19) and nutritional deficiencies. Unequal mobility exerts a powerful and variable influence on health access and outcomes (Gushulak, 2001, p. 265).3 In most Northern countries, legalization of immigration status is the principal determinant of timely access to quality preventative and curative care (Ottersen, et al., 2014, p. 649; WHO, 2010, pp. 12–13).4 Box 4.1 illustrates this point with reference to asylum seekers in Greece.5 With the exception of emergency care and health care for minors, furthermore, a 2014 Migration Code prohibits service providers in Greece from treating irregular migrants and all migrant-health care is compromised by the absence of “interpreters, cultural mediators and health care professionals trained in culturally competent health care approaches” (Cyril and Renzaho, 2016, pp. 235–236).

Box 4.1

Migration health policy in Greece

[A]sylum seekers who are legally recognized as refugees have equal access to the health care system as Greek citizens. However, the majority of asylum seekers whose application is in process and are awaiting their claim decision are not covered by any interim health schemes. This poses a great danger to their health as those requiring medical assistance often postpone their treatment in order to avoid out-ofpocket expenses for health care utilization and medication. Source: Cyril and Renzaho (2016, p. 235)

Migrant workers Around the world, migrant workers labor in unhygienic and unprotected conditions with limited access to health services (Hamada, 2017, p. 159; Ottersen, et al., 2014, p. 649; Renzaho, 2016a, pp. 136–137; Bustamante, 2010, p. 90; Satyen, et al., 2016, pp. 490, 496–497). More than 90 percent of California’s

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Box 4.2 Irregular migrants, deportation fears, and essential health services Dr. Luke Smith drove slowly through the unlit streets of a [Durham, North Carolina] neighborhood filled with immigrants, searching for an address among small houses with windows ribbed with iron bars. Pharmacy bags lay at his feet. His mission: to deliver medication to patients too frightened to pick up their prescriptions. On this evening, Dr. Smith, a psychiatrist, was looking for the family of a 12-year-old boy with attention deficit disorder. Like most people who have sneaked into the United States illegally, the boy’s parents, from Puebla, Mexico, do not have drivers’ licenses. Now, when they drive, being stopped at one of the frequent traffic checkpoints here can have consequences far more costly than a fine. Shaken by the Trump administration’s broad deportation orders, they and many others like them are retreating into the shadows, forgoing screenings, medications, and other essential medical care. Source: Hoffman (2017)

Indirect impacts Migration and health are indirectly as well as directly related in Northern contexts. Even the inclusion of a citizenship question in the U.S. decennial census risks underreporting total population in regions inhabited by large numbers of immigrants and, consequently, resulting in reduced funding for health-related programs. In addition, epidemiologists typically measure disease impact by comparing prevalence to total population size. Thus, “with skewed census data, public-health officials may invest in solving a problem that does not exist – or worse, may overlook one that does” (Baumgaertner, 2018). Mental health Dislocation increases vulnerability to psychiatric conditions among all migrants, with individuals experiencing different types and levels of distress at pre-migration, migration, and post-migration stages (Bhugra and Jones, 2001, pp. 219–220). Some migrants who experience extreme traumatic situations, including rape and torture, exhibit mental toughness and psychosocial resilience and adaptation. The persecuted, along with members of armed forces engaged in military operations outside their homeland and other migrants exposed to catastrophic situations, are prone to post-traumatic stress disorder (PTSD). Migrant mental disorders are subject to misdiagnosis by biomedical clinicians and psychotherapists.9 Therapist blinders are responsible for “overdiagnosing (misinterpreting culturally sanctioned behavior as pathological) and underdiagnosing (attributing psychiatric symptoms to cultural differences)” (Leong and Lau, 2001, pp.  206–207). Such misdiagnoses explain the decontextualized tendency to label problems that

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migrants experience as politically derived and widely shared non-pathological distress and suffering (Burnett and Peel, 2001, p. 608; Zarowsky, 2000) as PTSD or other forms of mental illness that carry burdensome social stigmas, as well as failures to recognize the extent to which migration results in depression and anxiety disorders (e.g., Ager, et al., 2002). Studies of refugee mental health have “tended to emphasize the impact of past events, particularly those in the country of origin and in the process of flight” and to pay little attention to “the impact of post-migration experiences on mental health” (Watters, 2001, p. 1711; also Koehn, 2005b, p. 60). However, as Caroline Gorst-Unsworth observes (1992, p. 165), migrants can survive torture, persecution, and repression in the home country only to encounter the equally powerful “trauma of exile, loss, insecurity, and discrimination in the country of refuge.”10 Post-departure stressors include worries about economic survival and persons left behind, pressures to remit money for families in the homeland (Haines, 2017, p. 83), living in unhealthy housing and under-resourced neighborhood (ibid., p. 79), loss of meaningful roles (Miller, 1999, pp. 284–285, 294–302) and social support, discrimination experiences (Liebkind, 1996, pp. 175–176), inequitable access to psychological services, and fear of being sent to an unsafe place of previous persecution (Watters, 2001, p. 1711; Silove, et al., 2002, pp. 459, 461; Silove, 2004, p. 94) compounded by delays in resolving uncertain immigration status (Reitmanova and Gustafson, 2009; Silove, et al., 1997, pp. 351, 353). There is considerable evidence that poverty and economic deprivation, financial strains that commonly affect irregular migrants, are “associated with an increased prevalence of mental disorders” (Walker, 2008, p. 138). These findings underscore the need for care providers who treat migrants to inquire regarding, and be competent to discern, the in-transit and in-country experiences that contribute to patient mental-health challenges (also Palinkas, et al., 2003, p. 20). Lacking transnational competence, primary-care providers often fail to discern migrant mental-health challenges and migration-connected stressors, to provide useful mental-health treatment, and to engage in effective referrals. Enhancing mental health requires transnationally competent inquiry regarding the specific ways that individual migrants articulate stressful experiences, define their mental-health needs, perceive their transnational involvements (Alcantara, Chen, and Alegria, 2015, pp. 492, 494), and utilize complementary and alternative methods of healing. Richard Mollica (2006, pp. 14–15, 100, 177) discovered that refugees who make it to the North possess an underappreciated capacity to recover from traumatic events and engage in self-healing through natural and imaginative wellnesspromoting strategies, including work, altruistic, and spiritual practices (also Bowen, et al., 2012, p. 61). The journey to psychosocial well-being can be further enhanced by focusing on activities that introduce joy, laughter, and hope in the lives of migrants, including entertainment programs, ethnospecific-culinary adventures (Gill, 2018), exposure to outdoor (sun-splashed) physical exercise (Reitmanova and Gustafson, 2009, p. 51; Mollica, 2006, pp. 196–197, 204–206), and sports play (Koehn and Koehn, 2016; Magra, 2018; Organista, et al., 2012, pp. 18–19).

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Dequalification and requalification Increasingly, remote and underserved inner-city areas in Northern countries are dependent on migrant physicians (Connell, 2010, p. 30; Koehn, et al., 2002; McNeil, 2017; Mullan, 2006, p. 386; Verghese, 2009, pp. 489–497; Oikelome and Healy, 2013, p. 571). At the same time, laws precluding recognition of the professional qualifications of immigrants, along with intersecting receiving society biases, serve as barriers to the employment of migrant professionals in valuable health-care capacities. For instance, “trained foreign nurses are employed as domestic workers performing demanding care tasks when they fail to get their professional qualifications acknowledged in order to work in formal care institutions” (Penttinen and Kynsilehto, 2017, p. 30; also Mavroudi and Nagel, 2016, pp. 76–77; Batnitzky and McDowell, 2011, pp. 197–198). Support for the requalification of migrant health professionals in destination countries constitutes an important step forward. During the requalification process, or when professional requalification is foreclosed, Northern initiatives have “taken advantage of the linguistic, cultural, and clinical knowledge possessed by migrant health professionals by employing them as intercultural mediators, health educators, and medical interpreters or translators” (WHO, 2010, p. 67; also p. 15).

The healthy-immigrant paradox and migrant contributions to healthy host practices The immigrant-health paradox refers to “observations that certain groups of immigrants – Latinos in particular – fare better by a number of indicators than do comparable U.S. populations (including non-immigrant Latinos), but that this advantage diminishes as immigrants live longer in the United States” (Cornelius and Gell-Redman, 2010, p. 2; also de Leon Siantz, 2016, pp. 345–347). The healthy-immigrant effect is documented in other Northern countries, including Australia, Canada, and the United Kingdom (Renzaho, 2016b, p. 375). Various explanations have been set forth to explain the healthy-immigrant paradox, including arrival from countries with healthier lifestyles (Renzaho, 2016b, pp. 376, 380; Ullmann, Goldman, and Massey, 2011, pp. 421–422), family cohesion and religious practice as protection against “the generally insalubrious contemporary U.S. lifestyle” (Cornelius and Gell-Redman, 2010, p. 2; Renzaho, 2016b, p. 383; de Leon Siantz, 2016, pp. 348–352, 354–355; Shirazi, Shirazi, and Bloom, 2015, pp. 154–155), success in cross-border migration by hardier individuals (de Leon Siantz, 2016, p. 353), and rigorous pre-migration screening (Renzaho, 2016b, p. 376). Although refugees undergo health screening prior to admission into Northern countries, there are multiple reasons to expect that the healthy-migrant effect would apply mainly to immigrants who are not refugees, asylum seekers, or irregular entrants (ibid., pp. 378–379).11 Access to health-care services in the United States likely can be ruled out as a contributing factor given that studies of immigrant and second- and third-generation Mexican

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Americans have found the widest disparities in access “for the generation closest to the immigrant experience” (Durazo and Wallace, 2014, pp. 1, 7).12 There is greater clarity regarding the deleterious effects of migrants’ lived experiences in the company of Northern diseases of affluence. Emotional stress, weight gain associated with the adoption of unhealthy dietary behavior, discrimination, and a rise in smoking and hazardous alcohol usage feature among the factors that negatively affect migrant health over time (Ullmann, Goldman, and Massey, 2011, pp. 422, 426–427; McMichael, Barnett, and McMichael, 2012, p. 650; Palinkas, et al., 2003, pp. 19–20; WHO, 2010, p. 37; de Leon Siantz, 2016, p. 353; Satyen, et al., 2016, pp. 483, 488–491).

Challenges of migrant-practitioner medical and public-health interactions Downstream from many of the sources of infectious disease and the onset of chronic illness in our increasingly borderless world, care seekers and health professionals come together in medical and health-promotion encounters. For migrants, “the medical interview holds the potential to undermine inequalities or to reproduce them” (Fox, 2000, p. 27). In light of practical barriers to patient-practitioner match and the absence of trained staff, migrant-practitioner medical and public-health interactions become particularly challenging both in detention centers and in host-community contexts. Even common ethnic identification offers no guarantee that medical practitioners will discern the extent to which migrant patients use traditional, complementary, and alternative therapies (Bauer and Guerra, 2014, pp. 3, 6–7). This section aims to unpack the critical factors that shape the expanding incidence of migrant interactions with Northern health providers and to offer a comprehensive and feasible approach to education and practice that will result in enhanced individual and societal outcomes. In transnational-medical encounters, professional expertise needs to be fused with lay wisdom and experience (El Ansari, et al., 2002, p. 156; Koehn and Sainola-Rodriguez, 2005, p. 301). Promising interfaces negotiate migrant and provider explanatory models of disease causation and prevention. In the approach to overcoming inequalities in status and health outcomes developed here, the foundational value of treating the experience of illness from the migrant’s perspective through Arthur Kleinman’s perceptive contribution of explanatory models is joined with the benefits that arise from facilitating transnationally competent (TC) health-care interactions on the part of all parties. Juxtaposing explanatory models When applied to migrant-health care, the promise of Kleinman’s insights rest with the juxtaposition of explanatory models. Placing medical beliefs sideby-side facilitates recognition and comparative study of a variety of explanatory frames “from the concepts of scientific medicine through those of other

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professional medical forms to folk beliefs and ‘commonsense’ popular ideas” (Kleinman, 1980, p. 104): The study of practitioner EMs [explanatory models] tells us something about how practitioners understand and treat illness. The study of patient and family EMs tells us how they make sense of given [specific] episodes of illness, and how they choose and evaluate particular treatments. The study of the interaction between practitioner EMs and patient EMs offers a more precise analysis of problems in clinical communication. (Kleinman, 1980, pp. 105–106) Most fundamentally, the analysis enabled by the comparative investigation of alternative explanatory systems “discloses one of the chief mechanisms by which cultural and social structural context affects patient-practitioner and other health care relationships” (ibid., p. 105) along with outcomes. The common reluctance of patients to share their explanatory model presents a serious challenge to practitioners in migrant/provider health-care interactions (e.g., Seto-Nielsen, et al., 2012, p. 2725). Kleinman (1980, p. 106n) maintains, however, that EMs can be elicited in clinical settings if health professionals are persistent and demonstrate a genuine, non-judgmental interest in patients’ beliefs and . . . express the conviction to patients that knowledge of their EMs is important to plan an appropriate treatment regimen. To elicit details regarding a patient’s EM in situations where general, openended questions prove unrevealing, Kleinman (ibid., p. 106n) suggests what has become an iconic set of eight exploratory questions: 1 2 3 4 5 6 7 8

What do you call your problem? What name does it have? What do you think has caused your problem? Why do think it started when it did? What does your sickness do to you? How does it work? How severe is it? Will it have a short or long course? What do you fear most about your sickness? What are the chief problems your sickness has caused for you? What kind of treatment do you think you should receive? What are the most important results you hope to receive from the treatment?

Community-facilitated approaches The multidisciplinary collaborative approach to transitioning from treatment to disease prevention and health promotion utilized by the San Diego Refugee Health Services Consortium incorporates Kleinman’s eight questions and offers additional potential advantages in Northern contexts. Sequencing begins with

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addressing mental-health issues that constitute barriers to participation in prevention programs. The second stage “involves addressing the immediate concerns of infectious disease risk.” This process requires recognizing “the patient’s conceptualization of the illness experience; his or her understanding of the cause, severity, and prognosis of an illness; the expected treatment; and how the illness affects his or her life” along with trusted provider/educator-negotiated and communitypartner-supported efforts to address misconceptions (Palinkas, et al., 2003, p. 26). The third stage “involves addressing the longer term concerns of chronic disease risk associated with acculturation and adoption of the health-related behavior of developed nations” – particularly through interventions focused on nutrition, alcohol consumption, smoking, and exercise (ibid., pp. 20–22). Other studies (e.g., Shirazi, Shirazi, and Bloom, 2015; Organista, et al., 2012, p. 20) identify the value of faith-informed, community-based framings of health determinants that encourage health-promoting behaviors among immigrants. In the public-health realm, community-health workers such as promotoras “educate providers about the community’s health needs” at the same time that they build community capacity (Vega and Cherfas, 2012, pp. 333, 341–342). Further, involving community intercultural mediators and “patient navigators” can provide Northern providers with invaluable insights and indispensable support for treatment recommendations that respect a patient’s explanatory framework (WHO, 2010, pp. 14, 44).

Contributions based on transnational-competence preparation In a context of increasing population mobility, many health outcomes are shaped by transnational interactions among care providers and recipients who meet in settings where nationality/ethnic match is a diminishing option. Throughout the North, health workers are encountering care users in spatial transition from a multitude of dissimilar nation states or ethnic communities. In transnational consultations, clinicians and patients often must deal with a wide variety of unfamiliar health threats and behaviors. In addition to multiple nationalities, physicians are challenged by evolving bicultural and multicultural patients and by third-culture (different from both origin and host) interactions (see Kasinitz, 2004, p. 293; Marginson, 2009, pp. 228, 237). The multidimensional nature of human experience generates considerable intragroup variation and complexity (see, for instance, Duffy, 2001, pp. 490–491; Gerrish, Husband, and Mackenie, 1996, p. 20). Migrant patients rarely present the same backgrounds and mobility experiences (Lipson and Meleis, 1999, pp. 89–90). While education holds out the promise of contributing to the reduction of disparities in health care, many domestically focused medical-school curriculums, residency programs, and continuing-education initiatives have not kept up with the transformative transnational-health challenges arising in our era of global mobility. Furthermore, “the possibility of physicians working to improve contextual sources of distress” has been “overlooked” in medical education (Waitzkin, 1991, p. 5). Addressing social and political barriers to greater equity in access to

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health care falls outside the scope of most medical-school curriculums (Wear, 2003, p. 551; 2006, p. 97; Betancourt, et al., 2005, p. 501). Culture-competence education also is of limited utility in today’s dynamic, diverse, hybrid, and complex patient-care environment (Koehn, 2006a; Carrillo, 2012, pp. 41, 43; Marginson, 2009, p. 228). Practitioners graduating from some culture-centered programs are prone to stereotyping, to making inaccurate assumptions (Beach, Saha, and Cooper, 2006, p. 563), and to missing the diversity of backgrounds, perspectives, and behaviors that exists within groups due to different social origins, unique and mixed experiences and identities, and extent of sustained transnational participation. In individual encounters, health professionals need to be cognizant of the dynamic interplay with culture of gender, socio-economic status, power position, discrimination, persecution, mobility and mobility disruptions, multiple and blended identities, and transborder connections (Koehn and Rosenau, 2010, Chapter 10; Seto-Nielsen, et al., 2012, pp. 2723, 2726). Migrants possess both “roots in multiple places and futures that may involve multiple places” (Haines, 2017, p. 137). In short, one outcome of health and medical education and practice in a mobility-infused world must be skill in identifying and addressing the special circumstances that surround and define the individual care recipient. The comprehensive set of practical skills that form the core of a transnational-competence (TC) curriculum promise to reinforce new initiatives and redirect traditional medical-school and public-health education in constantly evolving ways that specifically and effectively work with connections among poverty, displacement, discrimination, and health disparities. TC approaches transnational-medical and health encounters as micro-level interpersonal interactions that occur in a social/power context and are shaped by macro level (global, regional, national, and local) structural factors. Advocacy is a conceptually integral skill component in TC preparation. Across its five skill domains, the TC curriculum remains focused on two primary and interconnected objectives: improved health outcomes and reduced health inequities for dislocated men, women, and children as well as for disadvantaged individuals and communities. Both objectives lie at the core of the People’s Charter for Health that emerged from the People’s Health Assembly held at Savar, Bangladesh, in 2000 (see Narayan and Schuftan, 2004, pp. 236–240). Consistent with Kleinman’s explanatory-framework approach, TC education is based on patient-centered learning. The medical consultation is approached as a partnership, with the patient participating as teacher as well as learner. The patient’s voice is treated as an indispensable source of expertise and experiential insight (Gerrish, Husband, and Mackenie, 1996, p. 36; Popay and Williams, 1996, pp. 760–762). As Melanie Tervalon and Jann Murray-Garcia (1998, p. 121) point out, “Only the patient is uniquely qualified to help the physician understand the intersection of race, ethnicity, religion, class, and so on in forming his (the patient’s) identity and to clarify the relevance and impact of this intersection on the present illness or wellness experience” – that is, “how little or how much culture has to do with that particular clinical encounter.” Rather

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than ignoring the perspectives of the least advantaged,13 then, preparation for the TC encounter involves a focus on patient-oriented inquiry that aims to promote congruent and complementary perspectives among care seekers and care providers on health status and health promotion regardless of national origin, ethnicity, cultural identity(ies), or socio-economic status. The TC framework explicitly encompasses five discrete, but mutually reinforcing, skill domains. Transnational competence involves mastery of analytic, emotional, creative/imaginative, communicative, and functional skills. Each skill domain encompasses multiple dimensions.14 Transnational-analytic skills The analytic domain of the TC curriculum focuses on developing the ability to gather and analyze relevant evidence related to the patient’s health rather than relying on stored knowledge that rapidly becomes obsolete. Both ethnocultural and boundary spanning socio-political analysis are required (Kim, et al., 2013, pp. 187–188). In global health, boundary spanning involves a mindset for learning that goes upstream: to draw out general or global lessons from the particulars of the local; downstream: for effectively applying global guidance for local practice and evaluating its relevance; and also laterally: for learning from different and comparable contexts. (Sheikh, et al., 2016, p. 3) To avoid misinterpreting messages and explanations offered by patients, students must develop expanded receptors for discerning glocal political and socioeconomic determinants of individual health (see Farmer, et al., 2013, p. 335; Gupta and Yick, 2001, p. 44; Lustig and Koester, 1996, pp. 60–61). Practitioners possessing transnational-analytic skill are able to comprehend critically the internal and external forces that affect migration health by expanding the medical discourse to include linked macro-structural and micro “origins of personal suffering” (Waitzkin, 1991, pp. 276, 4, 11) – such as armed conflict (Smedley, Stith, and Nelson, 2003, p. 205), powerlessness, global manipulations of national and subnational economies (Kickbusch and Buse, 2001, pp. 713, 724; Zwi and Yach, 2002, p. 1617), corporate contributions to the nutrition transition (Hawkes, 2006), foreign-policy interventions (Koehn, 1991, pp. 40–45, 58–98, 392–394, 400–405), persecution (Koehn, 1991), and the type, combination, and frequency of trauma experiences (Silove, 2004, p. 93). They are able to identify the full range of professional and institutional actors, including transnational networks of state and non-state elites, who are positioned to shape local and distant policies affecting health care in particular settings (Buse, et al., 2002, pp. 259, 263–267; Redwood-Campbell, et al., 2011, p. 4). TC analytic preparation also connects individualized attributes of class, identity(ies) (e.g., Liu, 2016, pp. 192–193), transnationality (Faist, et al., 2015, p. 195; Vega and Cherfas, 2012, p. 333),15 and power to practical efforts to discern

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and analyze critically specific proximate and distant political, economic, social, and environmental determinants of physical and mental health “variability, vulnerability, and strength” (Kagawa-Singer and Kassim-Lakha, 2003, p. 579). In short, TC-prepared practitioners avoid the trap of adopting an exclusively ethnic/ cultural focus that “obscures the social and structural basis of the need” (Gerrish, Husband, and Mackenie, 1996, p. 34). Consistent with the core-teaching recommendations of the Society of General Internal Medicine Health Disparities Task Force, moreover, the TC curriculum facilitates analysis of “the existence and magnitude of health disparities, including the multifactorial causes of health disparities and the many solutions required to eliminate them” and the relationship of disparities in health care to disparities in individual and population health (Smith, et al., 2007, pp. 656, 658). Utilizing analytic techniques transnationally requires special preparation. First, TC educators emphasize eliciting comprehensive narratives and biopsychosocial explanatory frameworks by moving beyond the prevalent “brief and perfunctory social history” (Green, Betancourt, and Carillo, 2002, pp. 193–197). They also teach strategies to avoid stereotyping. Students quickly discover that shared ethnicity does not necessarily mean shared culture.16 As Robert Like (2007, slide 30) reminds us, “Within-group diversity is often greater than between-group diversity.” Students learn to gather and utilize relevant evidence about the care seeker’s homeland, migration experiences, ethnicity, cultural, and spiritual practices, economic situation, degree of societal incorporation, support systems, populationspecific disease incidence/prevalence/outcomes, new and emerging diseases, and antimicrobial resistance. TC-trained students learn to identify and access reliable secondary sources (including the internet17 and telemedicine along with the published and current research findings of knowledgeable social and behavioral scientists), to locate and learn from proximate and highly regarded ethnic- and diaspora-community leaders, ethnic-health specialists, extended-family members, and other care providers. The evidence gathered provides a starting point for physical/mental-health inquiry, confirmation, disconfirmation, enriched and refined analysis, and recommended therapies/referrals. Specifically, in preparing to care for migrants, students learn to consider key distant and proximate factors, including dislocation and migration experiences, altered nutrition practices, and the extent (and positive and negative effects) of adaptation (see Kasinitz, 2004, p. 286). In light of the existence of national subcultures and the presence of intracultural (and changing) variations that occur due to “age, gender, income, education, acculturation, individual differences, and multiple other factors,” general epidemiological evidence about the patient’s country and its endemic diseases, ethnic group, or religious affiliation is “regarded as having some bearing but requires further validation to be considered immediately useful” (Shapiro and Lenahan, 1996, pp. 251–252, 254–255; also KagawaSinger and Kassim-Lakha, 2003, p. 582). Insight into the barriers that impede access in the receiving country also requires context-specific and individualized (specific identities, beliefs, values, socio-economic status, capabilities, and experiences) analysis (Kovandzic, et al., 2012, pp. 536, 547; Carrillo, 2012, p. 54). A

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TC program emphasizes skill in discerning the lifestyle and health consequences of the patient’s changing class profile – often characterized by radical downward mobility in the case of involuntary (politically dislocated) and irregular migrants and upward mobility for voluntary (economic) migrants – along with exposure to new risks and the adoption of detrimental health behaviors in North. It is important that medical practitioners elicit and explore the longitudinal dimensions of spatial transition as migrants often are dealing with “unfinished endings” that preceded their arrival in the current locale (Lipson and Meleis, 1999, p. 89; Meleis, et al., 1995, p. 10) and continue to shape their lives and aspirations for the future. Thus, transnational-analytic skill further involves unraveling existing linkages among migrant health and post-migration constraints and stressors associated with local reception practices (Eastmond, 1998, p. 178; Koehn, 2006c). For instance, a patient’s capacity for self-care may be limited by ongoing “cultural and linguistic isolation, fragmentation of the family, deformation of social relationships, chronic absence of adequate support systems, poverty, prejudice, and unemployment” (Allden, 1998, p. 32) – all rooted in migration and post-migration experiences. Furthermore, events and conditions in the sending country often continue to affect the mental health and physical well-being of migrants who possess transnational ties and identities (Lipson and Omidian, 1996, pp. 12, 14; Rynearson and Phillips, 1996, pp.  13–14; Fong, 2009, p. 353). The presence of relatives in multiple geographic contexts further complicates transnational affinities and healthseeking behavior, particularly when reunions are precluded by travel restrictions. Linnea Kessing and colleagues (2013, pp. 431–432, 435–438) found that daily preoccupation with cross-border emotional and financial concerns and priorities left “little room for participating in mammography screening” among migrant women in Denmark. A central component of TC-analytic skill, therefore, is the ability to construct a “mini ethnography” of health, illness, and migration/adaptation experiences (see Koehn and Swick, 2006, pp. 552–553). In the transnational-health encounter, the care petitioner’s narrative of lived experience – including stressful social and environmental situations (Organista, et al., 2012, pp. 8–13), networks of transnational social relations, fluid and emerging identities – should be highly regarded by care providers.18 In order to discern fully Latino/a migrants’ hybrid and selective sexual practices that condition HIV risks, for instance, Hector Carrillo (2012, pp. 42–43, 45, 49, 53–54) alerts us to the importance of exploring how the observed diversity reflects their experiences prior to migration, their continued interactions with their home countries, their interactions in the host country, and the [rapid and continual] processes of social and cultural change taking place in both the migrants’ home countries and in the North. The mini-ethnography approach reduces prospects that decisions will be based on stereotypic oversimplifications and/or insufficient information and helps

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practitioners avoid the tendency to perceive and treat all migrants as somatized and/or traumatized victims (Eastmond, 1998, pp. 177–179). In addition, the rarely treated multiplace and multiprovider context of contemporary health care needs to be discerned, respected, and addressed (see Koehn and Tiilikainen, 2007, pp. 2–9). Transnational mobility is a life-long, multi-generational process that “involves complex interactions between migrants, second-generation family members and those left behind” (Zhou, et al., 2017, p. 645). In their multisited study of Chinese transmigrants who maintain “very close connections” with their country of origin through daily electronic communication and return travel, Yanqiu Zhou and colleagues (2017, pp. 645–647) found it rewarding to explore how settlement processes, including “changes in intimate relationships,” shape HIV “risk perceptions, risk exposure and risk responses” in light of “the simultaneous influence of the home-country context.” Specifically, they identify a critical health-impacting “disjuncture between Chinese immigrants’ [durable sendingcountry shaped] views (including misconceptions and silence about HIV) and their changing sexual practices in a post-immigration context.”19 Another useful transnational-analytic skill in migration health is the ability to ascertain the role of ethnocultural and other nonstandard health-related beliefs, values, practices, and paradoxes. The TC-prepared practitioner also inquires regarding other providers the care seeker has interacted with, what multiple and possibly competing explanations s/he has received, and what other treatments s/he is using or has used. TC training prepares health-care providers to assess the role of nonbiomedical considerations in the pre-and post-migration explanatory model and decision-making processes of specific presenters and/or families (DeSantis, 1997, p. 26). They also learn to search out and integrate information concerning the pharmacological properties of the user’s ethnocultural preparations (ethnopharmacology) (Smedley, Stith, and Nelson, 2003, p. 205). Box 4.3 presents illustrative TC learning components in the analytic domain.

Box 4.3 Illustrative TC-curriculum components: analytic domain 1

Develop the conceptual framework for analyzing the particular socioeconomic and political factors that influence health-care delivery for the individual patient a

b c

Recognize the need to move upstream and downstream along the health chain. Uncover variable contextual social forces and power relations Recognize that moving upstream and downstream intergenerationally is likely to yield divergent as well as overlapping insights Develop consciousness that individual medical care alone cannot be sufficient to sustain practices that will maximize the patient’s health potential (Hirsch and Vasquez, 2012, p. 114)

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Connect concepts of class, identity, power, and distancing to the ability to discern and to analyze critically (Wear, 2003, p. 552) the variable proximate effects and distant political/economic/social/ environmental contributors to health “variability, vulnerability, and strength” (Kagawa-Singer and Kassim-Lakha, 2003, p. 579; CMHS, 2001, p. IV2). Specifically, analyze the interaction of: i linked macro and micro, local, and global forces ii structural inequities embedded in conditioning institutions iii dislocation experiences (including types and extent of persecution and trauma) iv migration decisions and experiences v forms of migration – forced, planned and long-term, planned and short-term (Saker, et al., 2004, p. 37)

e

Connect concepts of class, identity, power, and distancing to the ability to discern post-migration conditions affecting the patient’s current health-related beliefs and practices and physical and mental health in the receiving society: i social/political experiences and stressors ii protection issues (Cahill, 2017, p. 47) iii simultaneous and potentially conflicting home- and hostcountry expectations and medical treatment iv differential access to health-care system and treatment opportunities v altered nutrition practices vi occupational and employment transitions vii (il)literacy viii housing & transportation situation ix (lack of) support networks x extent, and positive and negative effects, of adaptation (see Kasinitz, 2004, p. 286) and changing class profile

2

3

Develop understanding of how, as provider, the degree of one’s cultural, ethnic, and socio-economic match to the patient influences the interaction (CMHS, 2001, p. IV5). Learn to avoid the “cultural blind spot syndrome” where the clinician assumes no distinctive health-care beliefs/practices exist because the patient looks and behaves much the same way s/he does (Buchwald, et al., 1994) Develop ability to utilize analytic techniques transnationally a b c

by eliciting comprehensive patient narratives and explanatory frameworks. by identifying and accessing reliable secondary sources by using general information about patient’s homeland, migration experiences, ethnicity, cultural, and spiritual practices, economic situation,

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degree of societal incorporation, support systems, populationspecific disease incidence/prevalence/outcomes, new and emerging diseases, and antimicrobile resistance (Saker, et al., 2004, p. 52) as a starting point for physical/mental-health inquiry, confirmation/disconfirmation, and recommended therapies/referrals by locating and learning from helpful proximate and current sources i ii iii iv v

e

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ethnic community ethnic-health specialists other care providers (nurses, social workers) telemedicine and the Internet published research findings

by accessing and relating information regarding the pharmacological properties of users’ ethnocultural preparations

Transnational-emotional skills Transnational-emotional competence involves the ability to express interest in new cultural patterns – language, family life, dietary practices (see Sharma, et al., 1999), customs, etc. (Like, 2004). It includes the ability to gain and maintain sensitivity and genuine respect for a multiplicity of values, beliefs, traditions, experiences, challenges, communication styles, and feelings of satisfaction and emotional distress stemming from social circumstances (Waitzkin, 1991, p. 23). TC-prepared practitioners possess the capacity to realize health-care insights through transnational empathy. This emotional skill is supported by treating other perspectives as distinctive rather than as inferior or deviant and by generating an appropriate emotional response to care seekers’ feelings and problems. In the migrant-health interface, it also is particularly important that care providers learn to respect rather than dismiss lay expertise (Popay and Williams, 1996; Gerrish, Husband, and Mackenie, 1996, p. 36) and nonbiomedical practices that affect acceptance of and compliance with treatment protocols and, therefore, influence health outcomes (see Oster, Thomas, and Darol, 2000, pp. 184–185, 272). Thus, TC-prepared practitioners take seriously lay beliefs regarding the mediating effect of randomness on health and well-being. Further, emotionally skillful participants appreciate that every medical encounter is a multidimensional interaction among the cultures of the patient, the physician, the support professional(s), and the health-care contexts/systems that surround them (see Nunez, 2000, p. 1072; Smedley, Stith, and Nelson, 2003, p. 126. The emotional-competence domain further emphasizes appreciation for the strengths and resilience of people in spatial transition. Many “refugee patients and their families bring to health consultation stories of incredible human resilience in the most extreme circumstances” (Stanton, Kaplan, and Webster, 1999/2000, p. 27; also DeSantis, 1997, p. 27; Koehn, 2005b, p. 65; Astier, 2008, p. S9). Studies

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show that a sense of personal, family, and/or group efficacy constitutes a powerful determinant of the adoption and maintenance of health-promoting actions and is associated with a host of health-enhancement and illness-prevention outcomes (Bandura, 1995, pp. 25–28, 35; Schwarzer and Fuchs, 1995, pp. 262–268, 277, 280). Under the vulnerable and stressful environmental conditions that migrants face as the result of formidable language and cultural constraints, discrimination, legal limbo, the threat of long-term unemployment, and/or lack of social support, provider appreciation for patient/family health-care assets/capabilities and for manageable self-care responsibilities reinforces individual and collective perceptions of transnational efficacy and strengthens confidence and perseverance to sustain new and/or demanding psychological and physiological health-enhancing behaviors (Jerusalem and Mittag, 1995, pp. 177–180, 194–195, 199; Schwarzer and Fuchs, 1995, pp. 280–281). In migrant-health care, “the ability to identify assets in a family beset by overwhelming liabilities” and vulnerabilities “often produces the turning point toward successful interventions” (McPhatter, 1997, p. 269 [emphasis in original]). The bases for resilience vary among patients and are subject to change over time (Lothe and Heggen, 2003, p. 314). Possibilities to explore include hopeful vision for the future, religious faith, self-reliance, personal history of overcoming adversity, finding meaning/purpose in life, and community assistance and support. Providers reinforce/restore efficacy by demonstrating appreciation for resilience, achievements, and successes in overcoming dislocation challenges and/or disparities in treatment, and by conveying an optimistic outlook regarding prospects that the health-care seeker’s needs can be addressed. TC-prepared practitioners are equipped with a toolkit of ways of (1) reinforcing and expanding resilience, (2) reversing devaluation and disempowerment by providing opportunities to demonstrate and develop role competence and increased control over one’s life both in and beyond health-care situations, and (3) enabling migrants to resist the adoption of health-adverse behaviors practiced by members of the receiving society. Emotional competence also involves life-long openness to critical self-appraisal and to promoting one’s emotional growth (Salovey, Woolery, and Mayer, 2001, pp. 280–281). The motivation-skill dimension of TC-emotional competence involves sustaining passion for engaging in transnational activities and rectifying disparities in health and health care along with cultivating and maintaining reflection, critical self-appraisal, stereotyping/bias remediation, and cultural humility (Tervalon and Murray-Garcia, 1998, pp. 118–119).20 Box 4.4 presents illustrative TC-curriculum components in the emotional-skill domain.

Box 4.4 Illustrative TC-curriculum components: emotional domain 1

Develop abilities to realize health-care insights through transnational empathy, to be effective at deciphering the patient’s perspective, to

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2

take seriously problems as the ethnoculturally discordant patient experiences them, and to generate an appropriate emotional response to the patient’s feelings Develop ability to reinforce/restore patient efficacy a

b 3

4

121

by demonstrating appreciation for achievements and successes (resilience and self-care) in overcoming dislocation and migration challenges and/or disparities in treatment (CMHS, 2001, p. IV5) by conveying an optimistic outlook on prospects that the patient’s health-care needs can be met (Newnes and Holmes, 1999, p. 277)

Develop ability to show respect for (acknowledge and validate) patient’s ethnocultural and other nonbiomedical health beliefs (including beliefs regarding mediating effect of luck, chance, personal destiny) and practices – to treat them as distinctive rather than inferior or deviant (Davison, Frankel, and Smith, 1992) Develop ability to motivate health improvements through transnational sociophysiologic feedback (Adler, 2002). This ability is important because many patients from non-Western cultures look for help in dealing with the emotional aspects of chronic or other illness and are shocked when clinicians approach their case only in terms of technical efficiency (Searight, 2003)

Transnational creative skills Practitioners cannot activate healthier directions if they cannot perceive and articulate them. The freeing up of creative capacities is a powerful force for positive health outcomes in the transnational-medical encounter. A key creative skill in the TC practice of migrant-health care is the ability to initiate and reinforce fruitful connections among distant and proximate parts of the patient’s experience and identity (Greene, 1995, p. 30; Seto-Nielsen, et al., 2012, p. 2723; Marginson, 2009, pp. 239–242). Skillful transnational clinicians are “creative synthesizers” (Bochner, 1981, p. 17) who are able to inspire and collaborate with participants (patients, family members, and cultural mediators) of diverse and multiple identities in the co-design and nurturing of innovative and contextually appropriate action plans (Seto-Nielsen, et al., 2012, p. 2719; Cahill, 2017, pp. 70, 96).21 Care providers are constantly searching transborder trajectories for plausible futures, ever vigilant for unanticipated and serendipitous possibilities – including the “new ideas and new approaches to health” arising in the South that “have real relevance and application in rich countries” (Crisp, 2010, pp. 14–15). A substantial proportion of all health care is provided “outside the perimeter of the formal health care system” (Kleinman, Eisenberg, and Good, 1978, p. 251). In the migrant-health arena, innovative approaches to managing needs for medical treatment and health protection include complementary integrations of biomedical, alternative, and ethnocultural explanatory frameworks and

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health-related practices (Oster, Thomas, and Darol, 2000, pp. 186–187; Skaer, et al., 1996, p. 33; Kleinman, 1980, p. 105). For instance, Lisa Seto-Nielsen and colleagues (2012, pp. 2719, 2724–2725) found that migrants enrolled in cardiac rehabilitation creatively and judiciously “considered, assessed, and blended knowledges from cardiac rehabilitation, experience with their own bodies and general ‘wisdoms’ passed on within their own and other immigrant communities.” The service petitioner’s own ideas, suggestions, resources, and ingenuity feature prominently in the mutually formulated TC-health plan. TC-prepared practitioners are able to articulate physical and emotional experiences that shaped the decision to leave the homeland as well as those encountered during migration and resettlement processes and relate both to approaches that effectively address the patient’s current health-promotion needs (Johnson, Higginbotham, and Briceno-Leon, 2001, p. 249) and to promising social changes and policy alternatives (Waitzkin, 1991, pp. 9, 23). Such creative approaches incorporate multilevel and multilocational linkages of individual, family, and community strengths (Fong, 2009, pp. 354, 358), empowering socio-political possibilities, and favorable ecological conditions (see Johnson, Higginbotham, and Briceno-Leon, 2001, p. 262; Martens and Hall, 2000). Thus, TC-prepared health professionals aim to become “master synthesizers” of local meanings and transnational processes (Janes, 2004, p. 468). Box 4.5 presents illustrative TC-curriculum components in the creative/ innovative domain.

Box 4.5 Illustrative TC-curriculum components: creative domain 1

2

3

4 5

6

Ability to account for the ethnoculturally discordant care seeker’s unique life context (physical and emotional experiences and institutional forces) in the tailored health-action plan Ability to account for the care seeker’s current place-specific environment (housing, social disorganization, transportation, etc.) in the tailored health-action plan Ability to activate, reinforce, and incorporate the care seeker’s own ideas, suggestions, resources, and ingenuity into the mutually agreedupon health plan (Seto-Nielsen, et al., 2012, p. 2726) Ability to forge synergetic and congruent linkages between what the care seeker believes and what the care provider believes Ability to articulate a health plan based on shared transnational synthesis – a complementary combination of biomedical and personal ethnocultural/mixed cultural health-care beliefs/practices that is neither clinically nor culturally contraindicated (CMHS, 2001, p. III5, 10; Tervalon, 2003, p. 573; Fadiman, 1997, pp. 266–268) Ability to construct a health-promotion action plan that includes societal reinforcement of linked physical/mental-health interventions (CMHS, 2001, p. III5)

Migrant health in Northern reception countries 7 8

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Ability to “adapt clinical or discipline-specific skills and practice in a resource-constrained setting” (Jogerst, et al., 2015, p. 244) Ability to adapt “global resources to address local priorities” (Frenk, et al., 2010, p. 1952)

Transnational-communicative facility Effective provider/patient communication is widely perceived as “a core competency in the health care profession” (Fox, 2000, p. 27; also see Smedley, Stith, and Nelson, 2003, pp. 141, 200). What is at stake is the ability to elicit critical information and to convey health-care options and recommendations across technical, literacy, linguistic, socio-cultural, and transnational boundaries. Increasingly, moreover, transnational-communicative competence is valuable in interactions with a linguistically diverse body of health-care professionals and staff. Transnationally sensitive communication promises to contribute to substantial improvements in the health status of vulnerable populations (Kreps, 2006, p. 8). While personal linguistic fluency in the patient’s first language is an immense behavioral asset, language-concordant practitioners seldom are available in transnational-health-care situations and striving to prepare physicians and other health-care professionals who are able to practice in the receiver’s first language is impractical when the health-care situations providers face involve multiple and changing first languages (see Zweifler and Gonzalez, 1998, pp. 1058, 1060). In New York City, for instance, care seekers might speak one of 150 different languages (Bernstein, 2005). Thus, the TC approach emphasizes skill in using an interpreter and the importance of employing skilled medical interpreters (Smedley, Stith, and Nelson, 2003, p. 192; WHO, 2010, p. 62). TC-prepared providers employ best practices associated with the participation of interpreters in health consultations (Tervalon, 2003, pp. 572–573) and facility in speech-simplification strategies. The latter is particularly important when care receivers are not literate (Smith, et al., 2007, p. 658). Transnationally skillful actors also develop proficiency in nonverbalcommunicative behavior. In medical encounters, “nonverbal communication skills .  .  . are as important as verbal skills, if not more so” (Waitzkin, 1984, p. 2445). In transnational-medical interactions, interview pace, and the use of “continuers” are particularly useful in order to ensure that participants are not rushed, prematurely interrupted, ignored, or incompletely understood (DiMatteo, 1997, p. 9). In addition, communication-recovery skills, such as humor, apology, and admission that one does not know everything, “reinforce confidence as well as competence because, when it is known that there is something to fall back on, one is less likely to avoid interactions that may prove difficult” (Kavanagh, 1999, p. 245; also see Tervalon and Murray-Garcia, 1998, p. 119). The capacity to engage in meaningful dialogue and to facilitate mutual selfdisclosure via questioning is particularly important in transnational-health-care situations characterized by vast social distance (DiMatteo, 1997, pp. 7, 11).

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When migrant perspectives on personal health and illness are withheld from or incongruent with the perceptions of host clinicians, their health-care needs cannot be addressed fully and effectively. Public-health professionals are challenged to comprehend health issues from the migrant’s perspective, while health-service recipients benefit from understanding provider perspectives (see Koehn, 2007, pp. 1055–1056). TC-communicative-skill preparation opens the door for the negotiation of appropriate treatment plans and for reinforced commitment to health-care agreements by developing the ability to create a collaborative atmosphere where encounter participants are comfortable expressing serious doubts, concerns, and disagreements (DiMatteo, 1997, p. 8; Waitzkin, 1991, p. 273). This skill is enriched by active listening. TC-prepared practitioners also are ready to provide thorough, contextually comprehensible, and appropriate explanations to care seekers. They utilize tailored health-promotion campaigns that employ community-relevant messages, cultural idioms (Palinkas, et al., 2003, pp. 23–25), and trusted media.22 In connection with HIV prevention, Miriam Vega and Lina Cherfas (2012, pp. 330–331, 337) insightfully distinguish surface-structure communication from deep-structure communication. Surface-structure communication matches the “superficial” social, linguistic, and appearance characteristics of a target population,23 while deepstructure communication “addresses values, norms, and interpersonal scripts that go beyond language and phenotypic similarity” and shape behavior. Surface-structure communication expands receptivity to health messages and deep-structure communication increases individual salience (ibid., p. 331). Communication approaches that incorporate both dimensions enhance “the likelihood that participants will come, stay, and consequently change behaviors, with subsequent overall increases in serostatus awareness and decreases in HIV incidence rates” (ibid.; also p. 346). Distributing phone cards, utilizing musical messaging and popular theater, and religious pledges can be effective surface-communication strategies with migrants prone to HIV risk (Organista, et al., 2012, pp. 18–20; Carrillo, 2012, pp. 47–48). Interpersonally tailored nonverbal communication enhances deep-structure communication (Vega and Cherfas, 2012, p. 331). Box 4.6 presents illustrative TC-curriculum components in the communicativeskill domain.

Box 4.6 Illustrative TC-curriculum components: communicative domain 1 Ability to select the most helpful interpreter for each patient’s specific cultural, linguistic, and social context 2 Ability to use best practices associated with the participation of interpreters in clinical consultations (Tervalon, 2003, pp. 572–573) 3 Proficiency in patient-appropriate non-verbal communication 4 Proficiency in active listening 5 Ability to use speech-simplification strategies

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6 Communication-recovery skills 7 Ability to facilitate mutual self-disclosure (Kagawa-Singer and KassimLakha, 2003, p. 580) 8 Ability to convey health-care options and recommendations across technical, linguistic, and cultural divides 9 Facility with E-Health, mobile, and wireless technologies (McCracken and Phillips, 2017, p. 374) 10 Ability to use “reverse” telemedicine to access knowledgeable healthcare providers in a migrant’s country of origin 11 Ability to elicit the migrant’s ethnocultural identification(s) and personal (including nonbiomedical) beliefs and practices regarding the causes, treatment, and prevention of illness 12 Ability to elicit questions and concerns 13 Ability to elicit doubts and disagreements

Transnational-functional adroitness Functional competence involves the interpersonal as well as technical ability to accomplish tasks and achieve objectives. In transnational-medical encounters, the functional skills of both patients and clinicians affect illness management and wellness promotion (Brach and Fraserirector, 2000, pp. 182–183). In migrant-health-care consultations, effective functional interventions take into account both the individual’s condition and the social context affecting health behavior (Johnson, Higginbotham, and Briceno-Leon, 2001, p. 252). Skill in establishing positive interpersonal relations is particularly valuable for the functional domain of migrant-health care. Learning to relate to diverse care seekers in ways that build mutual trust is a prerequisite for TC-functional-skill development. Keys to success in building trusted and fruitful migrant care interpersonal relationships include demonstrating sustained personal as well as professional interest in the migrant as an individual – that is, showing that one sincerely is interested in, respects, and cares about the care seeker’s current situation, social inclusion (Duffy, 2001, p. 491), quality of life, and aspirations (and not just his/her physical health). TC-prepared medical providers who demonstrate ability to resolve conflicts to mutual satisfaction and to build trust enhance prospects for positive migrant-health outcomes through impacts on patient satisfaction, access, and adherence to recommended treatments (Calnan and Calovski, 2015, p. 383). In medical encounters, the functional dimension of transnational competence is promoted by establishing clinician/patient partnerships or “therapeutic alliances” (Tervalon and Murray-Garcia, 1998, p. 121). In the transnationaltherapeutic alliance, “the process of negotiation between practitioner and patient involves developing courses of action that are consistent with the patient’s values and goals and that also satisfy the physician’s values and goals” (DiMatteo, 1997, p. 13). For many migrants, transculturally sustainable agreements necessitate

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involvement by (extended) family and/or migrant-community support networks (Kleinman, Eisenberg, and Good, 1978, p. 257). Negotiating a mutually agreedupon and situationally tailored health/treatment plan with diverse care seekers and their families involves learning how to resolve differences between the practitioner’s professional agenda and expectations, and the personal agenda and expectations of participating care receivers (Smith, et al., 2007, p. 659). Functionally adroit practitioners recognize that cultural sensitivity alone is insufficient to remedy health and health-care disparities (see Betancourt, et al., 2005, p. 503). A passionate commitment to reducing inequities and skill in advocating for the health of disadvantaged patients and communities also are needed (George, Gonsenhauser, and Whitehouse, 2006, p. 73; Redwood-Campbell, et al., 2011, pp. 1, 4–5). In the case of migrants who lack voice in the socio-political context they find themselves in, concern for patient well-being is demonstrated by actions that address the institutionalized sources responsible for personal suffering (Waitzkin, 1991, pp. 23, 25, 11, 39). Supportive actions on behalf of migrant-health promotion include enabling further education and host-country-language training, facilitating credential (re)certification and employment (Palinkas, et al., 2003, p. 26), and challenging prejudice, bias, and discrimination whenever encountered in health-care settings or society. Efforts to address inequities include encouraging legal/policy coalition building with professional colleagues, stakeholder organizations, and (transnational) NGOs, and acting as the patient’s advocate within the medical/health establishment and with government agencies and community associations (Kovandzic, et al., 2012, pp. 544–547; Dutta, 2007, pp. 310, 315, 321–322; Hirsch and Vasquez, 2012, p. 104). Other valuable TCprovider interventions are facilitating access to traditional healers, medicine, and nutrition; encouraging the maintenance of children’s healthy practices (Kasinitz, 2004, p. 286; Barnes, Harrison, and Heneghan, 2004, pp. 353–354); promoting ties to community-support systems (Palinkas, et al., 2003, p. 25); and helping with transportation to medical appointments. It is likely to be particularly rewarding for effective functional-skill application to focus immediate-advocacy attention on local “hot spots” where migrants tend to congregate and to develop specific interventions that address site-specific and context-specific conditions that are conducive to elevated risk-taking behavior (Smith and Yang, 2005, p. 132). Another promising collective approach for migrant-health promotion is to focus on “reducing the excess exposures to health hazards of those occupying lower social positions” (Diderichsen, et al., 2001, pp.  19–20; Pamies and Nsiah-Kumi, 2009, p. 18) – including dangerous and unsanitary working conditions, exposure to hazardous wastes, homelessness (Bradley and Taylor, 2011), and unhygienic housing. In the interest of promoting equitable health opportunities for migrants, transnational-functional adroitness necessitates comprehensive advocacy competence – that is, recommendations/actions that will generate upstream and downstream changes in domestic and international economic, social, institutional, and policy conditions that produce the systemic disparities that constrain individual health and preclude the realization of health gains (Smedley,

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Stith, and Nelson, 2003, pp. 35–36, 185; Ford, 2013, pp. 137, 142; Farmer, 1999, pp. 10−15, 252; Kleinman, 1980, p. 104; Zwi and Yach, 2002, p. 1616). In functionally effective roles, health professionals apply transnational analytic,24 emotional, creative, and communicative skills toward mobilizing specific resources and support that will empower users by removing or reducing institutional barriers and societal challenges to positive health outcomes. Box 4.7 presents illustrative TC-curriculum components in the functional domain.

Box 4.7 Illustrative TC-curriculum components: functional domain 1 2

Ability to establish and maintain meaningful transnational interpersonal relations Ability to relate to ethnoculturally discordant patients in a way that builds mutual trust a b c

3 4

5

6

7

8

show that one genuinely is interested and cares about patient’s current situation and quality of life (beyond physical health) actions are regarded as appropriate and useful conflicts are resolved to mutual satisfaction

Ability to apply relevant insights from the other four TC domains in ways that accomplish tasks and achieve objectives Ability to integrate evidence-based insights regarding the influence of ethnocultural practices/predispositions, class, migration, trauma, and access into effective individually tailored health-care responses Ability to engage the care seeker (and/or his/her family) in making joint health/illness assessments and in developing/modifying health plans (i.e., ability to create therapeutic alliances) (see Fadiman, 1997, p. 266; Verwey and Crystal, 2002, p. 88) Ability to implement strategies that “engage marginalized and vulnerable populations in making decisions that affect their health and wellbeing” (Jogerst, et al., 2015, p. 244) Advocacy and referral skills I. Ability to build and activate hostsociety and migrant-community resources that are likely to enhance the care seeker’s health situation by addressing the site-specific challenges s/he confronts (Potocky, 2010a, pp. 130–131; Potocky, 2010b, pp. 121–122). User, service, and agency profiles (Fong, 2009, p. 359) are likely to be useful preparatory tools for the activation of effective referral and advocacy I initiatives Advocacy and referral skills II. Ability to build and activate societal resources that are likely to enhance the migrant’s health situation by mitigating the socio-economic inequities, power differentials, exclusion policies, and other institutionalized constraints s/he confronts (Mohan and Clark Prickett, 2010, p. 199)

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Migrant TC Prospects for positive migrant-health outcomes are greatly enhanced when care seekers as well as providers and other support professionals who interact with migrants (particularly those at the first point of contact) are transnationally competent (Koehn, 2005a; 2005b, pp. 65–69; WHO, 2010, pp. 15, 66–67). In their encounters with unmatched care providers (Greenhalgh, Collard, and Begum, 2005) and negotiations with Northern health systems and regulations (WHO, 2010, p. 15), most migrants find themselves challenged to interact successfully. To maximize opportunities for positive health outcomes, therefore, migrants also need access to enhanced transnational competence across all five dimensions. TC preparation enables migrants to participate effectively when negotiating a therapeutic plan with Northern health-care allies and when accessing indigenous healers, medicine, and nutrition − both locally and abroad. Migrant TC preparation should incorporate counseling regarding how to augment biomedical treatments with safe and complementary alternative and transnational-health-care practices, including familiar nutritional supplements (Kovandzic, et al., 2012, pp. 537, 543).

Transnational ties and migrant health Chapter 1 identified the diagnostic and continuous-care challenges arising from tourism and transnational-medical care. Migrant transnationality presents another potentially hidden “marker of heterogeneity” and investment in crossborder health protection that shapes or is conditioned by inequalities (Faist, et al., 2015, pp. 193, 195–196). The intensity of transnational involvements varies considerably by nationality, length of stay, and age of arrival in the North (see, for instance, Waldinger, 2007; Pitkanen, Icduygu, and Sert, 2012, p. 222). Some, but not all, migrants are positioned to “navigate multiple health systems and resources.” The range of flexible enablers that might be called upon to promote transnational health care include “paperwork to cross borders, information, referrals, tele-diagnosis, access to medications (both from places of origin and destination), access to traditional healers, and use of formal and informal health services in countries of origin and destination” (Villa-Torres, et al., 2017, p. 72; also p. 76). The decision by migrants to seek out health care in the sending (or another) country can be prompted by numerous considerations. Foremost among these considerations are lack of confidence in receiving-country providers’ diagnosis and recommendations; dissatisfaction with an impersonal approach to medical care; cost, legal, language, and cultural barriers that restrict access to the formalcare system in the destination place; and confidence in augmented sendingcountry options (Villa-Torres, et al., 2017, pp. 76–77; Jervelund and Handlos, 2015, p. 235; Gonzalez-Vazquez, Pelcastre-Villafuerte, and Taboada, 2016, pp. 1190, 1196; Choi, 2013, pp. 360, 362–363). Numerous studies document situations where migrants engage in transnational health care that involves their country of origin (see Villa-Torres, et al., 2017,

2

Introduction

at breakneck speed. Movers and non-migrating travelers spread communicable diseases to new human hosts, including to immobile persons inhabiting areas never exposed before (see, for instance, Tatem and Smith, 2010). In inescapable local places, transnational mobility “is generating epidemiological diversity and complexity” (Chen and Berlinguer, 2001, p. 36). Although morbidity and mortality associated with migration health “are the result (whether directly or indirectly) of local and international political decisions,” international relations, my field of study, has failed to keep pace with the manifold and complex linkages that bind politics with global health and transnational migration (Davies, 2010, pp. 2–3). For instance, the nature of armed conflict has fundamentally, and perhaps irreversibly, changed. Health personnel and facilities now are deliberately targeted. Civilian casualties are on the rise. Why should we care? First, because health is a human right. Everyone’s health matters. And, anyone can be health-secure today and health-vulnerable tomorrow. Further, it is costly not to act in a preventative manner. Negative fiscal and public-health consequences also can undermine political legitimacy and be politically disruptive. In a classic case, deliberate attempts by government authorities to conceal information about the initial SARS outbreak, coupled with institutional voids in preparedness, exacerbated the extent of transnational contagion, fanned public anger, and, ultimately, resulted in high-level disciplinary actions in China and Hong Kong (Olsson and Zhong, 2012; Koehn, 2007, p. 1053). We also are learning that health and well-being are imperatives if sustainable development is to be realized and the economic drivers of transnational migration are to be moderated. In addition, powerful appeals to people’s health concerns offer a promising way forward for the mobilization of actions aimed at mitigating drivers of climate change and attendant coastal displacement. At a fundamental level, migration “affects us all” (Dickenson, 2017, p. 7). The lived experiences of those who move impact those who stay behind and those on the receiving end. Transnational mobility brings the communicable presence and lifestyle-associated health practices and challenges of others to our doorsteps and catapults us into the hands of overseas caretakers and medical providers. Inescapably, we all inhabit the same health lifeboat (McCracken and Phillips, 2017, p. 16). From the shared lifeboat perspective, the lived health experiences of people on the move are at once illustrative, compelling, and personally relevant. Simply put, in the words of Nigel Crisp (2016, p. 8), “global health is the study, research, and practice concerned with issues that affect the health of us all wherever we live [at the moment].” The charge to the reader of Transnational Mobility and Global Health is to engage with empathy and foresight the pressing and arising issues of mobility, inequality, and global health (Penttinen and Kynsilehto, 2017, p. 157).

Mobility and health The useful concept of “mobility” covers various forms of human movement1 and encompasses the ability to migrate as well as the possibility of migration (Ionesco,

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serious illness, difficulty surrounding birth of new baby, or divorce)” confirm that “migration does not end with settlement but is rather a continuing process that is often characterized by ongoing ties to homeland kin through the use of ICTs and visits” (ibid., p. 401). Although long-distance communication often is less than fully emotionally and socially satisfying given “cultural notions of appropriate care” and obligations to kin, many migrants who would risk being unable to return North suffer from a heart-breaking inability to travel to the country of origin in spite of the transportation revolution (ibid., pp. 400, 402–403). Loretta Baldassar (ibid., p. 402) concludes that while transnational families manage to remain connected across distance, laws and policies regarding nation-state borders “have not kept pace with our increasingly mobile and multi-local lives.” Today’s Northern health-care providers are challenged by the frequency of transnational engagements and hybrid practices – where “migrants mix goods, ideas, and people between origin and host countries, all with the intention to maintain, improve, and regain their health” (Villa-Torres, et al., 2017, p. 76).26 By linking their spatially disconnected lifeworlds, for instance, migrants are transforming the boundaries of health care by introducing outlooks, possibilities, and helpful practices in origin as well as arrival places (Tiilikainen and Koehn, 2011). However, informed advice on how to incorporate transnational approaches into a complementary holistic physical-well-being and health plan typically is not forthcoming from most Northern biomedical providers. Northern clinicians and other public-health providers need to be prepared to help migrants who use cross-border health care. Specifically, a holistic, transnational approach is necessary in order to identify all contributors to mental disorders as well as the full complement of available and active health-promoting mechanisms that are part of the lived social world of migrants. All Northern providers require “more knowledge on the magnitude of use, the type of services used, the quality of care, and the prevalence of medical errors abroad, as well as the overall consequences and benefits for the patients and healthcare systems” (Jervelund and Handlos, 2015, p. 235). One of the keys to increased awareness is making inquiry into the “social resources and strains” encountered in transnational care standard practice in patient-provider interactions (Alcantara, Chen, and Alegria, 2015, p. 486). Too often, physicians in the North do not consider an individual’s transnational social world and are unaware of health-care inquiries, resources, and resilient practices that span borders (e.g., Seto-Nielsen, et al., 2012, p. 2725; Muecke, 1992, p. 520; DeSantis, 1997, p. 26). For instance, my field research revealed that Finnish principal attending physicians did not correctly identify the level of their migrant patient’s incorporation/non-incorporation of Somali health-care practices and failed to suggest an appropriate combination of biomedical and indigenous health-care approaches (Tiilikainen and Koehn, 2011; also see Seto-Nielsen, et al., 2012, p. 2725; Choi, 2013, p. 363).

Prospects for future health invasions from the South Massive in-migration from the South is largely responsible for unsettling contemporary politics across Europe and in the United States in the wake of rising

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xenophobia, popular misperceptions, and fanned threats (Mavroudi and Nagel, 2016, pp. 137, 184, 189; Porter and Russell, 2018; WHO, 2010, p. 13). Ours is an age where a “seemingly unstoppable tide of impoverished immigrants washes up (sometimes literally) on the shores of wealthy countries” (Mavroudi and Nagel, 2016, p. 2). Walls and prisons are not likely to stem unwelcomed flows (Koehn, 1991, p. 401). Ali Mazrui’s (1975, p. 126) predicted “demographic counterpenetration” is underway (see, for instance, Flahaux and De Haas, 2016, pp. 10, 13–15, 23; Garcia-Zamora, 2017, p. 584). Marie-Laurence Flahaux and Hein De Haas (2016, p. 22) caution, however, that it is misleading to characterize the level of extra-continental migration from Africa as an “invasion” of the North, particularly when compared with migration within Africa. It is important, then, that policy makers and citizens discern contemporary South-North population movements from an accurate27 and non-exaggerated perspective.28 Will health invasions from the South add to the count? Prospects that people will head North for health care increase as long as Southern health systems are inadequate to serve their growing populations and vast disparities in treatment options persist (Scott, 2005). Even Northern emergency-health care can look better than destroyed and abandoned health facilities and failed health systems. In some cases, moreover, we have seen that transnational-health practices and technological developments obviate the need for migrants to leave sendingcountry options completely behind. Mobile populations will be a “permanent feature” of Northern societies (WHO, 2010, p. 15). Climate change, threats to global health and human rights, unsustainable natural-resource consumption, and expanding economic inequities suggest that a compelling priority of civil-society-citizenship education must involve preparing all learners, including migrants, to participate in glocal projects that address transnational challenges where our interdependent destinies are at stake. Rather than disqualifying the migrants in one’s midst by insistence on common identity and territorially based rights, the defining and unifying feature of authentic contemporary citizenship can be participation in shared deterritorialized projects (Koehn and Ngai, 2006; Nicolaidis, 2006, p. 199). Because unifying projects and collective efforts are not confined to nation-state borders, preparation for civil-society citizenship is inescapably transnational. As a result of their transnationally lived experiences and the practical lessons they learn through the process of spatial transition, migrants bring valuable skills and commitments to the contemporary civil-society-citizenship table. In an age of dislocation, shared-project initiatives and interactions need to be informed and supported by expanded and enhanced educational capacity. Preparing migrants for civil-society citizenship through effective participation in collective public-health projects can be advanced by transnational-competence education. The TC framework offers particularly promising educational guidelines when preparing learners for civil-society citizenship (Koehn and Ngai, 2006). Individual and societal health benefits are most fully realized when all project participants are transnationally competent. There is evidence from projects involving migrant-health care that TC on the part of participants in transnational-health

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encounters is related to positive outcome assessments (Koehn, 2006b, 2006c). In turn, enhanced migrant health and resilience enables civil-society citizens to participate more deeply and effectively in shared projects and to interact confidently with authoritative decision makers.

Conclusion Effective migrant-health policy and provision are universally beneficial because “all members of a community are affected by the poor health status of its least healthy members” (Smedley, Stith, and Nelson, 2003, p. 37; also Buse, et al., 2002, p. 277). Policy makers need to heed WHO’s call for a “frank” inter-sectoral “discussion about the broader societal costs of poor migrant health” (WHO, 2010, p. 67). Recognition that (1) “extension to all peoples of the benefits of medical, psychological, and related knowledge is essential to the fullest attainment of health”29 and (2) that the concomitant right to essential socio-economic preconditions to health is vital (ibid., pp. 47, 49, 55; Bustamante, 2010, p. 90) embraces the guiding principles that underlie the approaches to migrant health in the global North set forth in this chapter. Minimizing the negative impact of the migration process on individual and societal health requires attention to the risks and stresses that vulnerable immigrants and host populations confront as part of the process of adapting to a new environment (WHO, 2010, p. 10). Europe’s migrant-friendly hospital movement (McMichael, Barnett, and McMichael, 2012, p. 651; WHO, 2010, pp. 61–62, 65)30 and transitioning to migrant-inclusive health systems and universal coverage (WHO, 2010, pp. 14, 64) constitute important steps in this direction. Arrivals and hosts both benefit from the early and effective diagnosis and treatment without stigmatization of infectious and non-infectious diseases (WHO, 2010, pp. 31–32, 39). Furthermore, it is time for a fresh, proactive, and mobility-relevant redirection of medical and public-health education. TC offers a competency-based curriculum that is comprehensive in scope, adaptable to a wide variety of service users and worldwide practice sites, and of utility in addressing both the quality of health care and social constraints on migration health. The TC curriculum (1) provides a comprehensive set of core competencies involving five ongoing skill-acquisition challenges; (2) accepts that acquired mastery of the “multiplicity of cultures” that define today’s migrant populations (Shapiro and Lenahan, 1996, p. 250) is neither feasible nor necessary for quality assurance and cost containment; (3) focuses on discerning each individual’s multiple and complex (rather than single-source) identities and distinctive health perspectives and personal needs; (4) places the physical- and mental-health consequences of economic disparities and underlying global/local structural contributors front and center; (5) aims to equip both service users and service providers with parallel and complementary skills; and (6) recognizes that empowering the multinational therapeutic alliance to deal with social-context challenges results in improved health outcomes and disparity reductions.31

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While transnational-health consultations constitute the principal or exclusive beneficial-care option for migrants in certain circumstances, such individual practices “are not addressing the fundamental causes of health inequities, but rather [are] circumventing the lack of transnational social protections” (VillaTorres, et al., 2017, p. 77). Powerful new upstream determinants, principally involving approaches to global governance at the intersections of health and migration policy, need to be activated. Improved transnational-health care is likely to feature in a promising collective approach that incorporates migrant experiences in Northern receiving countries and addresses access needs and barriers (Villa-Torres, et al., 2017, p. 78). Realizing this governance goal will require multiple multilevel32 and multi-sector (WHO, 2010, p. 21; Hirsch and Vasquez, 2012, pp. 104, 114) applications of the advocacy dimension of transnationalfunctional competence. In the next chapter, we retrace our focus from the Global North to the Global South. While Chapter 4 has been concerned with protecting the physical and mental health of migrants and receiving publics, Chapter 5 explores the powerful connections and tensions that exist among migration, health, and sustainable development.

Notes 1 Such late presentation is “associated with an increased likelihood of passing the virus on to others and with poorer therapeutic outcomes for those who receive antiretroviral therapy” (Hirsch and Vasquez, 2012, p. 104). 2 Chapters 2 and 3 treat health conditions in detention centers. On U.S. processing differences for refugees and asylum seekers, see Haines (2017, pp. 60–61). 3 In terms of personal and family health care, one should not overlook the diverse ingenuity, strategizing, and networking of asylum seekers and other immigrants faced with challenging circumstances in Northern receiving contexts (see Mavroudi and Nagel, 2016, pp. 143, 198, 205, 218, 224). 4 In exceptional actions, the Governments of Norway, Spain, and Italy entitled asylum seekers and irregular migrants to the same health coverage and conditions as citizens (WHO, 2010, pp. 14, 51; also see pp. 44, 46, 52–53). 5 To some extent, these shortcomings are ameliorated by the work of the medical humanitarian NGO Médecins du Monde-Greece, including the provision of open polyclinics frequented by asylum seekers (Cyril and Renzaho, 2016, pp. 242–246). 6 Undocumented immigrants rarely possess health insurance (e.g., Hirsch and Vasquez, 2012, p. 112) – a situation that did not change under the Patient Protection and Affordable Health Care Act of 2010. 7 On San Francisco’s efforts to work around such access constraints on behalf of undocumented migrants, see Morrow (2010, pp. 2–5) and Organista, et al. (2012, p. 17). 8 In January 2018, the Trump administration canceled the Temporary Protected Status program that allowed some 200,000 Salvadorans to live and work in the United States since 2001. The prospect of return to the upstream-seeded gang violence and extortion that permeates El Salvador stoked fear in the hearts of those affected and their family members who will remain in the USA (Palumbo and Ahmed, 2018). 9 In extreme cases, misdiagnoses and overdiagnoses can lead to treatment procedures that refugees and other migrants perceive to be “inappropriate and terrifying” (Pernice and Brook, 1996, p. 517).

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10 Almost all (93 percent) of the resident foreign nationals I interviewed in Finland who reported a mental-health concern indicated that their experiences in Finland had contributed to the problem they cited (Koehn and Sainola-Rodriguez, 2006; also see Sainola-Rodriguez and Koehn, 2006). 11 Unfortunately, “studies examining the healthy migrant effect do not examine the data by migration status” (Renzaho, 2016b, pp. 379, 384). 12 Mehra Shirazi and colleagues similarly found that Iranian women “who had lived in the United States for >10 years were more likely to have ever had a CBE [clinical breast examination] and mammogram” in comparison with newer immigrants (Shirazi, Champeau, and Talebi, 2006, pp. 494–495). 13 In her case study of Lia Lee’s treatment by U.S. doctors, Anne Fadiman (1997, pp. 259, 28) reports that Lia’s medical chart “grew longer and longer, until it contained more than 400,000 words . . . . [Yet] not a single one dealt with the Lees’ perception of their daughter’s illness.” 14 This discussion draws upon Koehn (2006a) and builds upon insights contributed by migrant patients interviewed in Finland as part of my Fulbright New Century Scholar research project. 15 Dual citizenship, for instance, can be perceived and pursued as a means of maximizing hybrid identities and transnational mobility (Liu, 2016, p. 197). 16 For an example, see “TB & Cultural Competency,” Northeastern Regional Training and Medical Consultation Consortium 6 (June 2007):4. 17 The Global Health Education Consortium provides a rich set of web-based resources and information on global health issues. www.globalhealth-ec.org/GHEC. 18 Genogram construction enriches the ethnographic interview. In the process of constructing genograms, one is able to identify “patterns of physical illness in families and the chains of losses, bereavements, abuse, and violence both within the family and towards the community” (Cook and England, 2004, pp. 110–111). 19 For instance, “the frequent or long-term separation of married spouses may, both in Canada and China, lead to extramarital sexual relations as a response to the intimacy vacuum caused by separation. Such behaviours, in turn, incur sexual health risks that were not experienced back home prior to immigration” (Zhou, et al., 2017, p. 647; also pp. 649–650). 20 Also GHC, “Mission and Vision.” https://ghcorps.org/why-were-here/mission-vision/; accessed 27 March 2018. 21 Also see GHC, “Mission and Vision.” https://ghcorps.org/why-were-here/mission-vision/; accessed 27 March 2018. 22 On the latter, see Kreps (2006, pp. 7–8). 23 On the limitations of static “culturally competent” messages, see Carrillo (2012, pp. 43–44). 24 TC-prepared health-care professionals recognize that “multisited ethnography must beget multilevel advocacy” (Janes, 2004, pp. 467–468). 25 International law protects migrants with life-threatening conditions that cannot be treated in their country of origin from forcible return (WHO, 2010, p. 53). 26 In spite of the frequency of Northern migrants’ transnational-health practices, “there have only been a handful of peer-reviewed empirical articles published in the past 25 years that explicitly incorporated a transnational perspective” (Villa-Torres, et al., 2017, p. 77). 27 As illustrations of inaccurate perceptions, Pew Research Center survey data suggest that 35 percent of Americans think the total average foreign-born is 40 percent or higher (versus the correct figure of 13 percent) and 36 percent think the percentage of that number that is unauthorized is 45 percent or higher (versus the correct figure of 26 percent) (Haines, 2017, p. 56; also pp. 58–60, 69–70; Porter and Russell, 2018, p. B1). 28 The use of disinformation to sensationalize the “caravan” of Central American migrants moving north through Mexico in April 2018 led President Trump to deploy

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National Guard troops in order to “secure our border between Mexico and the United States” (David, 2018, p. A1; also Peters, 2018). Constitution of the WHO. www.who.int/governance/eb/who_constitution_en.pdf. Also see the Amsterdam Declaration Towards Migrant-Friendly Hospitals in an Ethnoculturally Diverse Europe at www.mfh-eu.net/public/european_recommendations.htm; accessed 6 November 2017. Exploratory study suggests that TC skills can improve health-care outcomes in ethnoculturally discordant medical encounters (Koehn, 2005b, 2006b, 2006c). Further research is needed. Including multilateral coordination (WHO, 2010, p. 55). At the subnational level, local governments and NGOs are critically important actors in promoting migranthealth care in Northern contexts “because of their close proximity to the needs of migrants” (WHO, 2010, p. 15).

References Adler, Herbert M. 2002. “The Sociophysiology of Caring in the Doctor-Patient Relationship.” Journal of General Internal Medicine 17 (November):874–881. Ager, Alastair; Malcolm, Margaret; Sadollah, Sana; and O’May, Fiona. 2002. “Community Contact and Mental Health amongst Socially Isolated Refugees in Edinburgh.” Journal of Refugee Studies 15 (1):71–80. Alcantara, Carmela; Chen, Chih-Nan; and Alegria, Margarita. 2015. “Transnational Ties and Past-Year Major Depressive Episodes among Latino Immigrants.” Cultural Diversity and Ethnic Minority Psychology 21 (3):486–495. Allden, Kathleen. 1998. “The Indochinese Psychiatry Clinic: Trauma and Refugee Mental Health Treatment in the 1990s.” Journal of Ambulatory Care Management 21 (2):30–38. Astier M. Almedom. 2008. “Resilience Research and Policy/Practice Discourse in Health, Social, Behavioral, and Environmental Sciences over the Last Ten Years.” African Health Sciences 8 (December):S1–S13. Baldassar, Loretta. 2014. “Too Sick to Move: Distant ‘Crisis’ Care in Transnational Families.” International Review of Sociology 24 (3):391–405. Baldassar, Loretta; Nedelcu, Mihaela; Merla, Laura; and Wilding, Raelene. 2016. “ICTBased Co-Presence in Transnational Families and Communities: Challenging the Premise of Face-to-Face Proximity in Sustaining Relationships.” Global Networks 16 (2):133–144. Bandura, Albert. 1995. “Exercise of Personal and Collective Efficacy in Changing Societies.” In Self-Efficacy in Changing Societies, edited by Albert. Bandura. Cambridge: Cambridge University Press. Pp. 1–45. Barnes, Donelle M.; Harrison, Cara; and Heneghan, Richard. 2004. “Health Risk and Promotion Behaviors in Refugee Populations.” Journal of Health Care for the Poor and Underserved 15 (3):347–356. Batnitzky, Adina; and McDowell, Linda. 2011. “Migration, Nursing, Institutional Discrimination and Emotional/Affective Labour: Ethnicity and Labour Stratification in the UK National Health Service.” Social & Cultural Geography 12, No. 2 (March):181–199. Bauer, Ingrid; and Guerra, Juan J. 2014. “Physicians’ Knowledge and Communication about Traditional, Complementary and Alternative Medicine Use among Latino Patients at Kaiser Permanente, Oakland CA.” Field Action Science Reports, Special Issue 10:1–8. Baumgaertner, Emily. 2018. “Census Question May Be Bad for Health.” New York Times, 15 February, p. A18.

136

Migrant health in Northern reception countries

Beach, Mary C.; Saha, Somnath; and Cooper, Lisa A. 2006. The Role and Relationship of Cultural Competence and Patient-Centeredness in Health Care Quality. New York: The Commonwealth Fund, October. Bernstein, Nina. 2005. “Language Gap Called Health Risk in E.R.” New York Times, 21 April, p. C20. Berry-James, RaJade M. 2012. “Cultural Competency in Health Care: Standards, Practices, and Measures.” In Cultural Competency for Public Administrators, edited by Kristen A. Norman-Major and Susan T. Gooden. Armonk, NY: M.E. Sharpe. Pp. 181–196. Betancourt, Joseph R.; Green, Alexander R.; Carrillo, J. Emilio; and Park, Elyse R. 2005. “Cultural Competence and Health Care Disparities: Key Perspectives and Trends.” Health Affairs 24, No. 2 (March/April):499–505. Bhugra, Dinesh; and Jones, Peter. 2001. “Migration and Mental Illness.” Advances in Psychiatric Treatment 7:216–223. Bochner, Stephen. 1981. “The Social Psychology of Cultural Mediation.” In The Mediating Person: Bridges between Cultures, edited by Stephen. Bochner. Boston: G.K. Hall. Pp. 6–36. Bowen, Kathryn J.; Friel, Sharon; Ebi, Kristie; Butler, Colin D.; Miller, Fiona; and McMichael, Anthony J. 2012. “Governing for a Healthy Population.” International Journal of Environmental Research and Public Health 9:55–72. Brach, Cindy; and Fraserirector, Irene. 2000. “Can Cultural Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model.” Medical Care Research and Review 57 (Supplement 1):181–217. Bradley, Elizabeth H.; and Taylor, Lauren. 2011. “To Fix Health, Help the Poor.” New York Times, 9 December, p. A31. Buchwald, D.; Caralis, P.V.; Gany, F.; Hardt, E.T.; Johnson, T.M.; Mueche, M.A.; and Putsch, R.W. 1994. “Caring for Patients in a Multicultural Society.” Patient Care 28 (11):105–123. Burnett, Angela; and Peel, Michael. 2001. “The Health of Survivors of Torture and Organised Violence.” British Medical Journal 322, No. 7286 (March):606–609. Buse, Kent; Drager, Nick; Fustukian, Suzanne; and Lee, Kelley. 2002. “Globalisation and Health Policy: Trends and Opportunities.” In Health Policy in a Globalising World, edited by Kelley Lee, Kent Buse, and Suzanne Fustukian. Cambridge: Cambridge University Press. Pp. 251–280. Bustamante, Jorge. 2010. “Keynote Address.” In World Health Organization, Health of Migrants: The Way Forward. Report of a Global Consultation Held in Madrid, Spain, 3–5 March. Geneva: World Health Organization. Pp. 89–94. Cahill, Kevin M. 2017. Milestones in Humanitarian Action. New York: Fordham University Press. Calnan, Michael; and Calovski, Vid. 2015. “Medical Tourism and Trust: Towards an Agenda for Research.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 379–390. Calvasina, Paola; Muntaner, Carles; and Quinonez, Carlos. 2015. “Transnational Dental Care among Canadian Immigrants.” Community Dental Oral Epidemiology 43:444–451. Carrillo, Hector. 2012. “Sexual Culture, Structure, and Change.” In HIV Prevention with Latinos: Theory, Research, and Practice, edited by Kurt C. Organista. Oxford: Oxford University Press. Pp. 41–61. Center for Mental Health Services [CMHS], U.S. Department of Health and Human Services. 2001. Cultural Competence Standards in Managed Care Mental Health Services:

Migrant health in Northern reception countries

137

Four Underserved/Underrepresented Racial/Ethnic Groups. www.mentalhealth.samhsa.gov/ publications/allpubs/SMA00-3457/default.asp Choi, Jin Young. 2013. “Negotiating Old and New Ways: Contextualizing Adapted Health Care-Seeking Behaviors of Korean Immigrants in Hawaii.” Ethnicity & Health 18 (4):350–366. Connell, John. 2010. Migration and the Globalisation of Health Care: The Health Worker Exodus? Cheltenham, UK: Edward Elgar. Cook, Alice; and England, Rhiannon. 2004. “Pain in the Heart: Primary Care Consultations with Frequently Attending Refugees.” Primary Care Mental Health 2 (June):107–111. Cornelius, Wayne A.; and Gell-Redman, Micah. 2010. “Introduction: New Research on Migration and Health.” Field Actions Science Reports, Special Issue 2:1–5. Crisp, Nigel. 2010. Turning the World Upside Down: The Search for Global Health in the 21st Century. London: Royal Society of Medicine Press. Cyril, Sheila; and Renzaho, Andre M.N. 2016. “Invisible and Suffering: Prolonged and Systematic Detention of Asylum Seekers Living in Substandard Conditions in Greece.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 207–254. Davies, Sara. 2010. Global Politics of Health. Cambridge, UK: Polity Press. Davis, Julie H. 2018. “President Wants National Guard to Block Border.” New York Times, 4 April, pp. A1, A19. Davison, Charlie; Frankel, Stephen; and Smith, George D. 1992. “The Limits of Lifestyle: Re-assessing ‘Fatalism’ in the Popular Culture of Illness Prevention.” Social Science and Medicine 34 (6):679–684. de Leon Siantz, Mary Lou. 2016. “Hispanic Immigration and the Epidemiological Paradox.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 345–361. DeSantis, Lydia. 1997. “Building Health Communities with Immigrants and Refugees.” Journal of Transcultural Nursing 9 (1):20–31. Diderichsen, Finn; Evans, Timothy; and Whitehead, Margaret. 2001. “The Social Basis of Disparities in Health.” In Challenging Inequities in Health: From Ethics to Action, edited by Timothy Evans, Margaret Whitehead, Finn Diderichsen, Abbas Bhuiya, and Meg Wirth. Oxford: Oxford University Press. Pp. 13–23. DiMatteo, M. Robin. 1997. “Health Behaviors and Care Decisions.” In Handbook of Health Behavior Research II: Provider Determinants, edited by David S. Gochman. New York: Plenum Press. Pp. 5–22. Duffy, Mary E. 2001. “A Critique of Cultural Education in Nursing.” Journal of Advanced Nursing 36 (4):487–495. Duncan, Whitney L. 2014. “Transnational Disorders: Returned Migrants at Oaxaca’s Psychiatric Hospital.” Medical Anthropology Quarterly 29 (1):24–41. Durazo, Eva M.; and Wallace, Steven P. 2014. “Access to Health Care across Generational Status for Mexican-Origin Immigrants in California.” Field Actions Science Reports, Special Issue 10:1–10. Dutta, Mohan J. 2007. “Communicating about Culture and Health: Theorizing CultureCentered and Cultural Sensitivity Approaches.” Communication Theory 17:304–328. Eastmond, Marita. 1998. “Nationalist Discourses and the Construction of Difference: Bosnian Muslim Refugees in Sweden.” Journal of Refugee Studies 11 (2):161–181. El Ansari, Walid; Phillips, Ceri J.; and Zwi, Anthony B. 2002. “Narrowing the Gap between Academic Professional Wisdom and Community Lay Knowledge: Perceptions from Partnerships.” Public Health (116):151–159.

138

Migrant health in Northern reception countries

Fadiman, Anne. 1997. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York: Farrar, Straus and Giroux. Faist, Thomas; Bilecen, Basak; Barglowski, Karolina; and Sienkiewicz, Joanna J. 2015. “Transnational Social Protection: Migrants’ Strategies and Patterns of Inequalities.” Population, Space and Place 21:193–202. Farmer, Paul. 1999. Infections and Inequalities: The Modern Plagues. Berkeley: University of California Press. Farmer, Paul; Basilico, Matthew; Kerry, Vanessa; Ballard, Madeleine; Becker, Anne; Bukhman, Gene; Dahl, Ophelia; Ellner, Andy; Ivers, Louise; Jones, David; Meara, John; Mukherjee, Joia; Sievers, Amy; and Yamamoto, Alyssa. 2013. “Global Health Priorities for the Early Twenty-First Century.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 302–339. Flahaux, Marie-Laurence; and De Haas, Hein. 2016. “African Migration: Trends, Patterns, Drivers.” Comparative Migration Studies 4:1–25. Fong, Rowena. 2009. “Culturally Competent Practice in Social Work.” In The Sage Handbook of Intercultural Competence, edited by Darla K. Deardorff. Los Angeles: Sage. Pp. 350–361. Ford, Nathan. 2013. “The Political Context of Global Health and Advocacy.” In An Introduction to Global Health Ethics, edited by Andrew D. Pinto and Ross E.G. Upshur. London: Routledge. Pp. 136–147. Fox, Kenneth. 2000. “Provider-Patient Communication in the Context of Inequalities.” In Child Health in the Multicultural Environment, edited by Esther Silverman. Report of the 31st Ross Roundtable on Critical Approaches to Common Pediatric Problems. Columbus: Ross Products Division, Abbott Laboratories. Pp. 27–36. Frenk, Julio; Chen, Lincoln; Bhutta, Zulfiqar A.; Cohen, Jordan; Crisp, Nigel; Evans, Timothy; Fineberg, Harvey; Garcia, Patricia; Ke, Yang; Kelley, Patrick; Kistnasamy, Barry; Meleis, Afaf; Naylor, David; Pablos-Mendez, Ariel; Reddy, Srinath; Scrimshaw, Susan; Sepulveda, Jaime; Serwadda, David; and Zurayk, Huda. 2010. “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World.” Lancet 376 (4 December):1923–1958. Fuller, Thomas. 2016. “Healthy Food Everywhere But on the Table.” New York Times, 24 November, pp. A19, A25. Gann, Bob. 2013. “Understanding and Using Health Experiences: The Policy Landscape.” In Understanding and Using Health Experiences: Improving Patient Care, edited by Sue Ziebland, Angela Coulter, Joseph D. Calabrese, and Louise Locock. Oxford: Oxford University Press. Pp. 150–161. Garcia-Zamora, Jean-Claude. 2017. “The Global Wave of Refugees and Migrants: Complex Challenges for European Policy Makers.” Public Organization Review 17:581–594. George, Daniel; Gonsenhauser, Iahn; and Whitehouse, Peter. 2006. “Medical Professionalism: The Nature of Story and the Story of Nature.” In Professionalism in Medicine: Critical Perspectives, edited by Delese Wear and Julie M. Aultman. New York: Springer. Pp. 63–86. Gerrish, Kate; Husband, Charles; and Mackenie, Jennifer. 1996. Nursing for a Multi-Ethnic Society. Buckingham: Open University Press. Gill, Lorin E. 2018. “US Restaurants Host Refugee Chefs Who Offer a Taste of Home.” Missoulian, 25 June. Gonzalez-Vazquez, Tonatiuh T.; Pelcastre-Villafuerte, Blanca E.; and Taboada, Arianna. 2016. “Surviving the Distance: The Transnational Utilization of Traditional Medicine

Migrant health in Northern reception countries

139

among Oaxacan Migrants in the US.” Journal of Immigrant and Minority Health 18: 1190–1198. Gonzalez-Vazquez, Tonatiuh T.; Torres-Robles, Cristian A.; and Pelcastre-Villafuerte, Blanca E. 2013. “Utilizacion Transnacional de Servicios de Salud por Parte de los Migrantes Mexicanos en Estados Unidos.” Salud Publica Mexicanos 55 (S4):S477–S484. Gorst-Unsworth, Caroline. 1992. “Adaptation after Torture: Some Thoughts on the LongTerm Effects of Surviving a Repressive Regime.” Medicine and War 8:164–168. Green, Alexander R.; Betancourt, Joseph R.; and Carillo, J. Emilio. 2002. “Integrating Social Factors into Cross-Cultural Medical Education.” Academic Medicine 77 (3): 193–197. Greene, Maxine. 1995. Releasing the Imagination: Essays on Education, the Arts, and Social Change. San Francisco, CA: Jossey-Bass. Greenhalgh, Trisha; Collard, Anna; and Begum, Noorjahan. 2005. “Sharing Stories: Complex Intervention for Diabetes Education in Minority Ethnic Groups Who Do Not Speak English.” British Medical Journal 330, No. 7492 (March):628–633. Grondin, Danielle; Weekers, Jacqueline; Haour-Knipe, Mary; Elton, Akram; and Stukey, Julia. 2003. “Health-An Essential Aspect of Migration Management.” In World Migration 2003: Managing Migration Challenges and Responses for People on the Move, edited by Thomas L. Weiss. Geneva: International Organization for Migration. Pp. 85–93. Gupta, Rashmi; and Yick, Alice G. 2001. “Preliminary Validation of the Acculturation Scale on Chinese Americans.” Journal of Social Work Research and Evaluation 2 (1):43–56. Gushulak, Brian. 2001. “Health Determinants in Migrants: The Impact of Population Mobility on Health.” In Health, Migration and Return: A Handbook for a Multidisciplinary Approach, edited by Peter J. van Krieken. The Hague: T.M.C. Asser Press. Pp. 255–268. Hadler, Max W. 2015. “Migration and Patient Mobility in Latin America.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 313–332. Haines, David W. 2017. Immigration Structures and Immigrant Lives: An Introduction to the US Experience. Lanham, MD: Rowman & Littlefield. Hamada, Yuko. 2017. “South to South Migration in Asia: Opportunities, Challenges and Policy Implications for the Sustainable Development Goals of the 2030 Agenda for Sustainable Development.” In South-South Migration: Emerging Patterns, Opportunities and Risks, edited by Patricia Short, Moazzem Hossain, and M. Adil Khan. London: Routledge. Pp. 152–172. Hawkes, Corinna. 2006. “Uneven Dietary Development: Linking the Policies and Processes of Globalization with the Nutrition Transition, Obesity and Diet-Related Chronic Diseases.” Globalization and Health 2 (4). Hirsch, Jennifer S.; and Vasquez, Emily. 2012. “Mexico-U.S. Migration, Social Exclusion, and HIV Risk: Multisectoral Approaches to Understanding and Preventing Infection.” In HIV Prevention with Latinos: Theory, Research, and Practice, edited by Kurt C. Organista. Oxford: Oxford University Press. Pp. 103–120. Hoffman, Jan. 2017. “Sick with Worry: Unauthorized Immigrants, Shaken by Broad Deportation Orders, Are Foregoing Essential Medical Care.” New York Times, 27 June, pp. D1, D6. Janes, Craig R. 2004. “Going Global in Century XXI: Medical Anthropology and the New Primary Health Care.” Human Organization 63 (4):457–471. Jerusalem, Matthias; and Mittag, Waldemar. 1995. “Self-Efficacy in Stressful Life Transitions.” In Self-Efficacy in Changing Societies, edited by A. Bandura. Cambridge: Cambridge University Press. Pp. 177–201.

140

Migrant health in Northern reception countries

Jervelund, Signe S.; and Handlos, Line N. 2015. “Use of Cross-Border Healthcare among Immigrants.” In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and Johanna Hanefeld. Cheltenham, UK: Edward Elgar. Pp. 228–237. Jogerst, Kristen; Callender, Brian; Adams, Virginia; Evert, Jessica; Fields, Elise; Hall, Thomas; Olsen, Jody; Rowthorn, Virginia; Rudy, Sharon; Shen, Jiabin; Simon, Lisa; Torres, Herica; Velji, Anvar; and Wilson, Lynda L. 2015. “Identifying Interprofessional Global Health Competencies for 21st-Century Health Professionals.” Annals of Global Health 81 (2):239–248. Johnson, Nancy A.; Higginbotham, Nick; and Briceno-Leon, Roberto. 2001. “Best Practice and Future Innovations in Applying Social Science to Advancing the Health of Populations.” In Applying Health Social Science: Best Practice in the Developing World, edited by Nick Higginbotham, Roberto Briceno-Leon, and Nancy A. Johnson. London: Zed Books. Pp. 249–276. Kagawa-Singer, Marjorie; and Kassim-Lakha, Shaheen. 2003. “A Strategy to Reduce Cross-Cultural Miscommunication and Increase the Likelihood of Improving Health Outcomes.” Academic Medicine 78 (6):577–587. Kasinitz, Philip. 2004. “Race, Assimilation, and ‘Second Generations’, Past and Present.” In Not Just Black and White: Historical and Contemporary Perspectives on Immigration, Race, and Ethnicity in the United States, edited by Nancy Foner and George M. Fredrickson. New York: Russell Sage Foundation. Pp. 278–298. Kavanagh, Kathryn H. 1999. “Transcultural Perspectives in Mental Health.” In Transcultural Concepts in Nursing Care, 3rd edition, edited by Margaret M. Andrews and Joyseen S. Boyle. Philadelphia: Lippincott. Pp. 223–261. Kessing, Linnea L.; Norredam, Marie; Kvernrod, Ann-Britt; Mygind, Anna; and Kristiansen, Maria. 2013. “Contextualising Migrants’ Health Behavior: A Qualitative Study of Transnational Ties and Their Implications for Participation in Mammography Screening.” BMC Public Health 13:431–442. Kickbusch, Ilona; and Buse, Kent. 2001. “Global Influences and Global Responses: International Health at the Turn of the Twenty-First Century.” In International Public Health: Diseases, Programs, Systems, and Policies, edited by Michael H. Merson, Robert E. Black, and Anne J. Mills. Gaithersburg: Aspen Publishers. Pp. 701–732. Kim, Jim Yong; Porter, Michael; Rhatigan, Joseph; Weintraub, Rebecca; Basilico, Matthew; Van Der Hoof Holstein, Cassia; and Farmer, Paul. 2013. “Scaling Up Effective Delivery Models Worldwide.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 184–211. Kleinman, Arthur. 1980. Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine, and Psychiatry. Berkeley: University of California Press. Kleinman, Arthur; Eisenberg, Leon; and Good, Byron. 1978. “Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research.” Annals of Internal Medicine 88:251–258. Koehn, Justin; and Koehn, Jason. 2016. “Beach Volleyball with Refugees: A Testimonial.” Jeanette Rankin Peace Center Newsletter (Winter/Spring):4. Koehn, Nerissa N.; Fryer, George E. Jr.; Phillips, Robert L.; Miller, John B.; and Green, Larry A. 2002. “The Increase in International Medical Graduates in Family Practice Residency Programs.” Family Medicine 34, No. 6 (June):429–435. Koehn, Peter H. 1991. Refugees from Revolution: U.S. Policy and Third-World Migration. Boulder, CO: Westview Press.

Migrant health in Northern reception countries

141

Koehn, Peter H. 2005a. “Improving Transnational Health-Care Encounters and Outcomes: The Challenge of Enhanced Transnational Competence for Migrants and Health Professionals.” Proceedings of the Hospitals in a Culturally Diverse Europe Conference on Quality-Assured Health Care and Health Promotion for Migrants and Ethnic Minorities, Amsterdam, 9–11 December 2004. www.mfh-eu.net/conf/ results/ Koehn, Peter H. 2005b. “Medical Encounters in Finnish Reception Centres: AsylumSeeker and Clinician Perspectives.” Journal of Refugee Studies 18 (1):47–74. Koehn, Peter H. 2006a. “Globalization, Migration Health, and Educational Preparation for Transnational Medical Encounters.” Globalization and Health 2 (2):1–43. Koehn, Peter H. 2006b. “Health-Care Outcomes in Ethnoculturally Discordant Medical Encounters: The Role of Physician Transnational Competence in Consultations with Asylum Seekers.“ Journal of Immigrant and Minority Health 8, No. 2 (April):137–147. Koehn, Peter H. 2006c. “Transnational Migration, State Policy, and Local Clinician Treatment of Asylum Seekers and Resettled Migrants: Comparative Perspectives on Reception-Centre and Community Health-Care Practice in Finland.” Global Social Policy 6 (1):21–56. Koehn, Peter H. 2007. “Global Health and Human Rights: Challenges for Public-Health Administrators in an Era of Interdependence and Mobility.” In Handbook of Globalization, Governance, and Public Administration, edited by Ali Farazmand and Jack Pinkowski. Boca Raton, FL: CRC Press. Pp. 1045–1073. Koehn, Peter H.; and Ngai, Phyllis B. 2006. “Citizenship Education for an Age of Population Mobility and Glocally Interconnected Destinies.” Finnish Journal of Ethnicity and Migration 1, No. 1 (December):26–33. Koehn, Peter H.; and Rosenau, James N. 2010. Transnational Competence: Empowering Professional Curricula for Horizon-Rising Challenges. Boulder, CO: Paradigm Publishers. Koehn, Peter H.; and Sainola-Rodriguez, Kirsti. 2005. “Clinician/Patient Connections in Ethnoculturally Nonconcordant Encounters with Political-asylum Seekers: A Comparison of Physicians and Nurses.” Journal of Transcultural Nursing 16, No. 4 (October):298–311. Koehn, Peter H.; and Swick, Herbert. 2006. “Medical Education for a Changing World: Moving Beyond Cultural Competence into Transnational Competence.” Academic Medicine 81, No. 6 (June):548–556. Koehn, Peter H.; and Tiilikainen, Marja. 2007. “Migration and Transnational Health Care: Connecting Finland and Somaliland.” Siirtolaisuus: Migration 34 (1):2–9. Kovandzic, Marija; et al. [8 additional co-authors]. 2012. “The Space of Access to Primary Mental Health Care: A Qualitative Case Study.” Health & Place 18:536–551. Kreps, Gary L. 2006. “Communication and Racial Inequities in Health Care.” American Behavioral Scientist 49, No. 6 (2006):1–15. Leong, Frederick T.L.; and Lau, Anna S.L. 2001. “Barriers to Providing Effective Mental Health Services to Asian Americans.” Mental Health Services Research 3 (4):201–214. Liebkind, Karmela. 1996. “Acculturation and Stress: Vietnamese Refugees in Finland.” Journal of Cross-Cultural Psychology 27, No. 2 (March):161–180. Like, Robert C. 2004. “Developing and Implementing Cultural Competency Training Programs: What Are We Learning?” Presentation at the International Conference on Hospitals in a Culturally Diverse Europe, Amsterdam, 11 December. Like, Robert C. 2007. “Graduate and Undergraduate Cultural Competence Education.” PowerPoint presentation at the International Workshop on Culturally Appropriate Health Care by Culturally Competent Health Professionals, Caesarea, Israel, 9 October.

142

Migrant health in Northern reception countries

Lipson, Joan G.; and Meleis, Afaf I. 1999. “Research with Immigrants and Refugees.” In Handbook of Clinical Nursing Research, edited by Ada Sue Hinshaw, Suzanne L. Feetham, and Joan L.F. Shaver. Thousand Oaks, CA: Sage. Pp. 87–106. Lipson, Juliene; and Omidian, Patricia. 1996. “Health and the Transnational Connection: Afghan Refugees in the United States.” In Selected Papers on Refugee Issues IV, edited by Ann M. Rynearson and James Phillips. Arlington: American Anthropological Association. Pp. 2–17. Liu, Lisong. 2016. Chinese Student Migration and Selective Citizenship: Mobility, Community and Identity between China and the United States. London: Routledge. Lothe, Ellen A.; and Heggen, Kristin. 2003. “A Study of Resilience in Young Ethiopian Famine Survivors.” Journal of Transcultural Nursing 14 (4):313–320. Lustig, Myron W.; and Koester, Jolene. 1996. Intercultural Competence: Interpersonal Communication across Cultures, 2nd edition. New York: HarperCollins. Madianou, Mirca. 2016. “Ambient Co-Presence: Transnational Family Practices in Polymedia Environments.” Global Networks 16 (2):183–201. Magra, Iliana. 2018. “Greece’s Island of Despair: Thousands of Asylum Seekers Still Languish in Deplorable Conditions on Lesbos.” New York Times, 31 March, p. A4. Manjoo, Farhad. 2016. “A Shared Lifeline for Millions of Migrants.” New York Times, 22 December, pp. B1, B7. Marginson, Simon. 2009. “Sojourning Students and Creative Cosmopolitans.” In Creativity and the Global Knowledge Economy, edited by Michael A. Peters, Simon Marginson, and Peter Murphy. New York: Peter Lang. Pp. 217–255. Martens, Pim; and Hall, Lisbeth. 2000. “Malaria on the Move: Human Population Movement and Malaria Transmission.” Emerging Infectious Diseases 6, No 2 (April):103–110. Mavroudi, Elizabeth; and Nagel, Caroline. 2016. Global Migration: Patterns, Processes, and Politics. London: Routledge. Mazrui, Ali A. 1975. “The New Interdependence: From Hierarchy to Symmetry.” In The U.S. and World Development: Agenda for Action 1975, edited by James W. Howe. New York: Praeger. Pp. 118–131. McCracken, Kevin; and Phillips, David R. 2017. Global Health: An Introduction to Current and Future Trends. London: Routledge. McMichael, Celia; Barnett, Jon; and McMichael, Anthony J. 2012. “An Ill Wind? Climate Change, Migration, and Health.” Environmental Health Perspectives 120, No. 5 (May):646–654. McNeil, Donald G., Jr. 2017. “Travel Ban, Aimed at Terrorists, Touches Doctors in Hardto-Fill Jobs.” New York Times, 7 February, p. A12. McPhatter, Anna R. 1997. “Cultural Competence in Child Welfare: What Is It? How Do We Achieve It? What Happens without It?” Child Welfare 76 (1):255–278. Meleis, Afaf I.; Isenberg, Marjorie; Koerner, Jo E.; Lacey, Bernadine; and Stern, Phyllis. 1995. Diversity, Marginalization, and Culturally Competent Health Care Issues in Knowledge Development. Washington, DC: American Academy of Nursing. Miller, Kenneth E. 1999. “Rethinking a Familiar Model: Psychotherapy and the Mental Health of Refugees.” Journal of Contemporary Psychotherapy 29 (4):283–306. Mohan, Brij; and Clark Prickett, Julia E. 2010. “Macro Social Work Practice with Transmigrants.” In Transnational Social Work Practice, edited by Nalini J. Negi and Rich Furman. New York: Columbia University Press. Pp. 191–204. Mollica, Richard F. 2006. Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World. Orlando: Harcourt.

Migrant health in Northern reception countries

143

Morrow, Helen B. 2010. “Access Not Denied? The Role American Localities Can Play.” Field Actions Science Reports, Special Issue 2:1–6. Muecke, Marjorie A. 1992. “New Paradigms for Refugee Health Problems.” Social Science and Medicine 35 (4):515–523. Mullan, Fitzhugh. 2006. “Doctors for the World: Indian Physician Emigration.” Health Affairs 25 (2):380–393. Narayan, Ravi; and Schuftan, Claudio. 2004. “The People’s Health Movement: A People’s Campaign for ‘Health for All-Now’.” In Globalization and Health, edited by Richard L. Harris and Melinda Seid. Leiden, NL: Brill. Pp. 235–243. Newnes, Craig; and Holmes, Guy. 1999. “The Future of Mental Health Services.” In This Is Madness: A Critical Look at Psychiatry and the Future of Mental Health Services, edited by Craig Newnes, Guy Holmes, and Cailzie Dunn. Ross-on-Wye: PCCS Books. Pp. 273–284. Nicolaidis, Kalypso. 2006. “We, the Peoples of Europe .  .  .” In Globalization and State Power: A Reader, edited by Joel Krieger. New York: Pearson. Pp. 194–200. Núñez, Ana E. 2000. “Transforming Cultural Competence into Cross-Cultural Efficacy in Women’s Health Education.” Academic Medicine 75 (11):1071–1080. Oikelome, Franklin; and Healy, Geraldine. 2013. “Gender, Migration and Place of Qualification of Doctors in the UK: Perceptions of Inequality, Morale and Career Aspiration.” Journal of Ethnic and Minority Studies 39 (4):557–577. Organista, Kurt C.; Worby, Paula A.; Quesada, James; Kral, Alex H.; Diaz, Rafael M.; Neilands, Torsten B.; and Arreola, Sonya G. 2012. “The Urgent Need for StructuralEnvironmental Models of HIV Risk and Prevention in U.S. Latino Populations: The Case of Migrant Day Laborers.” In HIV Prevention with Latinos: Theory, Research, and Practice, edited by Kurt C. Organista. Oxford: Oxford University Press. Pp. 3–23. Oster, Nancy; Thomas, Lucy; and Darol, Joseff. 2000. Making Informed Medical Decisions: Where to Look and How to Use What You Find. Beijing: O’Reilly. Ottersen, Ole P.; and 23 co-authors. 2014. “The Political Origins of Health Inequity: Prospects for Change.” Lancet 383 (15 February):630–667. Painter, Thomas M.; Organista, Kurt C.; Rhodes, Scott D.; and Sanudo, Fernando M. 2012. “Interventions to Prevent HIV and Other Sexually Transmitted Diseases among Latino Migrants.” In HIV Prevention with Latinos: Theory, Research, and Practice, edited by Kurt C. Organista. Oxford: Oxford University Press. Pp. 351–381. Palinkas, Lawrence A.; Pickwell, Sheila M.; Brandstein, Kendra; Clark, Terry J.; Hill, Linda L.; Moser, Robert J.; and Osman, Abdikadir. 2003. “The Journey to Wellness: Stages of Refugee Health Promotion and Disease Prevention.” Journal of Immigrant Health 5, No. 1 (January):19–28. Palumbo, Gene; and Ahmed, Azam. 2018. “El Salvador again Feels the Weight of Washington in Shaping Its Fate.” New York Times, 10 January, p. A15. Pamies, Rubens J.; and Nsiah-Kumi, Phyllis A. 2009. “Addressing Health Disparities in the 21st Century.” In Cultural Proficiency in Addressing Health Disparities, edited by Sade Kosoko-Lasaki, Cynthia T. Cook, and Richard L. O’Brien. Sudbury, MA: Jones and Bartlett Publishers. Pp. 1–35. Penttinen, Elina; and Kynsilehto, Anita. 2017. Gender and Mobility: A Critical Introduction. London: Rowman & Littlefield. Pernice, Regina; and Brook, Judith. 1996. “Refugees’ and Immigrants’ Mental Health: Association of Demographic and Post-Immigration Factors.” Journal of Social Psychology 136 (4):511–519.

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Peters, Jeremy W. 2018. “How ‘the Caravan’ Story Exploded on the Right.” New York Times, 5 April, p. A11. Pitkanen, Pirkko; Icduygu, Ahmet; and Sert, Deniz. 2012. “Current Characteristics of Migrant Transnationalism.” In Migration and Transformation: Multi-Level Analysis of Migrant Transnationalism, edited by Pirkko Pitkanen, Ahmet Icduygu, and Deniz Sert. Dordrecht: Springer. Pp. 207–224. Popay, Jennie; and Williams, Gareth. 1996. “Public Health Research and Lay Knowledge.” Social Science and Medicine 42 (5):759–768. Porter, Eduardo; and Russell, Karl. 2018. “Migrants Are on the Rise around the World, and Myths about Them Are Shaping Attitudes.” New York Times, 23 June, pp. B1, B7. Potocky, Miriam. 2010a. “Social Work Practice in Refugee Resettlement.” In Transnational Social Work Practice, edited by Nalini J. Negi and Rich Furman. New York: Columbia University Press. Pp. 124–134. Potocky, Miriam. 2010b. “Social Work Practice with Victims of Transnational Human Trafficking.” In Transnational Social Work Practice, edited by Nalini J. Negi and Rich Furman. New York: Columbia University Press. Pp. 111–123. Pottie, Kevin; Hui, Chuck; and Schneider, Fabien. 2016. “Women, Children and Men Trapped in Unsafe Corridors.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 291–303. Redwood-Campbell, Lynda; Pakes, Barry; Rouleau, Katherine; MacDonald, Colla J.; Arya, Neil; Purkey, Eva; Schultz, Karen; Dhatt, Reena; Wilson, Briana; Hadi, Abdullahel; and Pottie, Kevin. 2011. “Developing a Curriculum Framework for Global Health in Family Medicine: Emerging Principles, Competencies, and Educational Approaches.” BMC Medical Education 11:46, 1–8. Reitmanova, Sylvia; and Gustafson, Diana L. 2009. “Mental Health Needs of Visible Minority Immigrants in a Small Urban Center: Recommendations for Policy Makers and Service Providers.” Journal of Immigrant and Minority Health 11 (1):46–56. Renzaho, Andre M.N. 2016a. “Health, Social and Economic Impact of Voluntary Migration.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 123–203. Renzaho, Andre M.N. 2016b. “Migration and the Healthy Migrant Effect in Australia: Current Knowledge, Gaps and Opportunity for Future Research.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 363–389. Rynearson, Ann M.; and Phillips, James. 1996. Selected Papers on Refugee Issues IV. Arlington: American Anthropological Association. Sainola-Rodriguez, Kirsti; and Koehn, Peter H. 2006. “The Mental-Health Needs of Political-Asylum Seekers and Resident Foreign Nationals in Finland: Patient Perspectives and Practitioner Recognition.” Journal of Social Medicine 43:47−59. Saker, Lance; Lee, Kelley; Cannito, Barbara; Gilmore, Anna; and Campbell-Lendrum, Diarmid. 2004. Globalization and Infectious Diseases: A Review of the Linkages. Geneva: World Health Organization. Salovey, Peter; Woolery, Alison; and Mayer, John D. 2001. “Emotional Intelligence: Conceptualization and Measurement.” In Blackwell Handbook of Social Psychology: Interpersonal Processes, edited by Garth J.O. Fletcher and Margaret S. Clark. Oxford: Blackwell Publishing. Pp. 278–307. Satyen, Lata; Toumbourou, John W.; Mellor, David; Secer, Ilmiye; and Ghayour-Minaie, Matin. 2016. “Migrant Health in the Workplace: A Multi-Country Comparison.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 479–507.

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Schwarzer, Ralf; and Fuchs, Reinhard. 1995. “Changing Risk Behaviors and Adopting Health Behaviors: The Role of Self-efficacy Beliefs.” In Self-Efficacy in Changing Societies, edited by Albert Bandura. Cambridge: Cambridge University Press. Pp. 259–288. Scott, Janny. 2005. “Life at the Top in America Isn’t Just Better, It’s Longer.” New York Times, 16 May, pp. A1, A18–A19. Searight, H. Russell. 2003. “Bosnian Immigrants’ Perceptions of the United States Health Care System: Qualitative Interview Study.” Journal of Immigrant Health 5 (2):87–93. Seto-Nielsen, Lisa; Angus, Jan E.; Lapum, Jennifer; Dale, Craig; Kramer-Kile, Marnie; Abramson, Beth; Marzolini, Susan; Oh, Paul; Price, Jennifer; and Clark, Alex. 2012. “‘I Can’t Just Follow Any Particular Textbook’: Immigrants in Cardiac Rehabilitation.” Journal of Advanced Nursing 68 (12):2719–2729. Shapiro, Johanna; and Lenahan, Patricia M. 1996. “Family Medicine in a Culturally Diverse World: A Solution-Oriented Approach to Common Cross-Cultural Problems in Medical Encounters.” Family Medicine 28 (4):249–255. Sharma, Sangita; Code, Janet; Riste, Lisa; and Cruickshank, Kennedy. 1999. “Nutrient Intake Trends among African-Caribbeans in Britain: A Migrant Population and Its Second Generation.” Public Health Nutrition 2 (4):469–476. Sheikh, Kabir; Schneider, Helen; Agyepong, Irene A.; Lehmann, Uta; and Gilson, Lucy. 2016. “Boundary-Spanning: Reflections on the Practices and Principles of Global Health.” BMJ Global Health 1. DOI: 10.1136/bmjgh-2016-000058 Shirazi, Mehra; Champeau, Donna; and Talebi, Aaron. 2006. “Predictors of Breast Cancer Screening among Immigrant Iranian Women in California.” Journal of Women’s Health 15 (5):485–498. Shirazi, Mehra; Shirazi, Aida; and Bloom, Joan. 2015. “Developing a Culturally Competent Faith-Based Framework to Promote Breast Cancer Screening among Afghan Immigrant Women.” Journal of Religion and Health 54:153–159. Silove, Derrick. 2004. “The Challenges Facing Mental Health Programs for Post-Conflict and Refugee Communities.” Prehospital and Disaster Medicine 19 (1):90–96. Silove, Derrick; Coello, Mariano; Tang, Kristina; Aroche, Jorge; Soares, Maria; Lingam, Rajina; Chaussivert, Marc; Manicavasagar, Vijaya; and Steel, Zachery. 2002. “Towards a Researcher-Advocacy Model for Asylum Seekers: A Pilot Study amongst East Timorese Living in Australia.” Transcultural Psychiatry 39 (4):452–468. Silove, Derrick; Sinnerbrink, Ingrid; Field, Annette; Manicavasagar, Vijaya; and Steel, Zachery. 1997. “Anxiety, Depression and PTSD in Asylum-Seekers: Associations with Pre-Migration Trauma and Post-Migration Stressors.” British Journal of Psychiatry 170 (April):351–357. Skaer, T.L.; Robinson, L.M.; Sclar, D.A.; and Harding, G.H. 1996. “Utilization of Curanderos among Foreign Born Mexican-American Women Attending Migrant Health Clinics.” Journal of Cultural Diversity 3 (2):29–34. Smedley, Brian D.; Stith, Adrienne Y.; and Nelson, Alan R. (eds.). 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press. Smith, Christopher J.; and Yang, Xiushi. 2005. “Examining the Connection between Temporary Migration and the Spread of STDs and HIV/AIDS in China.” China Review 5, No. 1 (Spring):111–139. Smith, Wally R.; Betancourt, Joseph R.; Wynia, Matthew K.; Bussey-Jones, Jada; Stone, Valerie E.; Phillips, Christopher O.; Fernandez, Alicia; Jacobs, Elizabeth; and Bowles, Jacqueline. 2007. “Recommendations for Teaching about Racial and Ethnic Disparities in Health and Health Care.” Annals of Internal Medicine 147:654–665.

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Migrant health in Northern reception countries

Stanton, J.; Kaplan, I.; and Webster, K. 1999/2000. “Role of Australian Doctors in Refugee Health Care.” Current Therapeutics 40, No. 12 (December/January):24–28. Tervalon, Melanie. 2003. “Components of Culture in Health for Medical Students’ Education.” Academic Medicine 78, No. 6 (June):570–576. Tervalon, Melanie; and Murray-Garcia, Jann. 1998. “Cultural Humility versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education.” Journal of Health Care for the Poor and Underserved 9 (2):117–125. Tiilikainen, Marja; and Koehn, Peter H. 2011. “Transforming the Boundaries of Healthcare: Insights from the Transnational Outlooks and Practices of Somali Migrants.” Medical Anthropology 30 (5):1–27. Ullmann, S. Heidi; Goldman, Noreen; and Massey, Douglas S. 2011. “Healthier before They Migrate, Less Healthy When They Return? The Health of Returned Migrants in Mexico.” Social Science & Medicine 73:421–428. Vega, Miriam Y.; and Cherfas, Lina. 2012. “The Landscape of Latina HIV Prevention Interventions and Their Implementation: Cultural Sensitivity in Community-based Organizations.” In HIV Prevention with Latinos: Theory, Research, and Practice, edited by Kurt C. Organista. Oxford: Oxford University Press. Pp. 329–349. Venters, Homer D.; Foote, Mary; and Keller, Allen S. 2011. “Medical Advocacy on Behalf of Detained Immigrants.” Journal of Immigrant and Minority Health 13, No. 3 (June):625–628. Verghese, Abraham. 2009. Cutting for Stone. New York: Vintage Books. Vertovec, Steven. 2010. “Super-Diversity and Its Implications.” In Anthropology of Migration and Multiculturalism: New Directions, edited by Steven Vertovec. London: Routledge. Pp. 65–95. Verwey, Sonja; and Crystal, Andrea. 2002. “Provider-Patient Communication in the African Health Context.” In Health Communication in Africa: Contexts, Constraints and Lessons, edited by Andy O. Alali and B.A. Jinadu. Lanham, MD: University Press of America. Pp. 81–108. Villa-Torres, Laura; Gonzalez-Vazquez, Tonatiuh; Fleming, Paul J.; Gonzalez-Gonzalez, Edgar L.; Infante-Xibille, Cesar; Chavez, Rebecca; and Barrington, Clare. 2017. “Transnationalism and Health: A Systematic Literature Review on the Use of Transnationalism in the Study of the Health Practices and Behaviors of Migrants.” Social Science and Medicine 183:70–79. Waitzkin, Howard. 1984. “Doctor-Patient Communication: Clinical Implications of Social Scientific Research.” JAMA 252, No. 17 (2 November):2441–2446. Waitzkin, Howard. 1991. The Politics of Medical Encounters: How Patients and Doctors Deal with Social Problems. New Haven: Yale University Press. Waldinger, Roger. 2007. Between Here and There: How Attached Are Latino Immigrants to Their Native Country? Washington, DC: Pew Hispanic Center, 25 October. Walker, Carl. 2008. Depression and Globalization: The Politics of Mental Health in the 21st Century. New York: Springer. Watters, Charles. 2001. “Emerging Paradigms in the Mental Health Care of Refugees.” Social Science and Medicine 52:1709–1718. Wear, Delese. 2003. “Insurgent Multiculturalism: Rethinking How and Why We Teach Culture in Medical Education.” Academic Medicine 78, No. 6 (June):549–554. Wear, Delese. 2006. “Respect for Patients: A Case Study of the Formal and Hidden Curriculum.” In Professionalism in Medicine: Critical Perspectives, edited by Delese Wear and Julie M. Aultman. New York: Springer. Pp. 87–101.

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World Health Organization (WHO). 2010. Health of Migrants: The Way Forward. Report of a Global Consultation Held in Madrid, Spain, 3–5 March. Geneva: World Health Organization. Zarowsky, Christina. 2000. “Trauma Stories: Violence, Emotion and Politics in Somali Ethiopia.” Transcultural Psychiatry 37 (3):383−402. Zhou, Yanqiu R.; Coleman, William D.; Huang, Yingying; Sinding, Christina; Su, Helen H.; Wei, Wei; Gahagan, Jacqueline; and Micollier, Evelyne. 2017. “Exploring the Intersections of Transnationalism, Sexuality and HIV Risk.” Culture, Health & Sexuality 19 (6):645–652. Zweifler, John; and Gonzalez, Anna Marie. 1998. “Teaching Residents to Care for Culturally Diverse Populations.” Academic Medicine 73 (10):1056–1061. Zwi, Anthony B.; and Yach, Derek. 2002. “International Health in the 21st Century: Trends and Challenges.” Social Science & Medicine 54 (11):1615–1620.

5

Migration, health, and sustainabledevelopment linkages Exploring southern contexts

Chapter 5 shifts the focus of attention from North to South. In what ways are health and migration, and their interconnections, drivers of, or barriers to, sustainable development? To what extent does population-health promotion serve as a vehicle for development-policy transformation, inter-sectoral analysis, and cross-agency collaboration? How do population health and mobility affect the factors and processes that facilitate and constrain sustainable development? The discussion of health/development interdependencies involves consideration of enabling conditions. Shaping processes include the impact of transnational trade and advertising on domestic health, resource-allocation decisions, out-migration, economic and social remittances, policy responses, NGO interventions, and boundary spanning. Chapter 5’s coverage includes health-care and development distortions attributable to the fatal flow of expertise, the internal drain of health-care professionals, task shifting, and the promise of circular migration. Pathways for turning vicious cycles into virtuous ones merit exploration. Identifying synergetic global health interventions that “harness a positive feedback loop between poverty reduction and health system strengthening” (Kim, et al., 2013, p. 194) are promising in this connection. The health of returning migrants and prospects for diaspora contributions to public health and sustainable development through physical and virtual circular migration also require attention (see Box 5.1).

Box 5.1 Two migrants who fled and then returned to contribute to health care in the sending-country “Ben Male fled from his schoolroom in Uganda when Idi Amin’s soldiers killed his father. Arriving in Tanzania [the 17-year-old boy] was mistaken for a spy by the rebel Ugandans preparing to invade the country and once again had to flee for his life. . . . By a remarkable chance missionaries [in Rwanda] introduced him to a British schoolteacher who . . . arranged for him to complete his schooling [in UK]. . . . Ben graduated from Sheffield University and after some years working for

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NGOs in Europe, returned to Uganda, where he is the country representative for Sightsavers.” Source: Crisp (2010, p. 67) In 2017, Dr. Munjed al-Muderis, an Iraqi-Australian orthopedic surgeon had returned to his hometown of Baghdad “for the first time since he escaped in 1999 after being ordered to cut off the earlobes of army deserters.” Using the surgical procedure osseointegration, which he helped pioneer for use on arms and legs, Dr. Muderis drilled titanium rods into remaining bone and attached them to advanced prostheses for dozens of amputees. Source: Baidawi (2017)

Health and development in the Global South: interacting influences By definition, countries in the Global South are struggling to develop. The political, economic, social, and cultural challenges of sustainable development are reflected in the local landscape of delivery of health services and access to health care (Kim, et al., 2013, pp. 186–187). Powerful upstream forces in the global economy, including pressures to privatize national health-care systems (Stewart, 2017, p. 119; Janes, et al., 2006; Moran, 2009, pp. 122, 126) and the promotion and increased availability of unhealthy products, such as tobacco, contribute to the heavy and inequitable burden of disease shouldered by resource-constrained countries in the South (MacLean and Brown, 2009, pp. 8, 14; McCracken and Phillips, 2017, p. 370; Koehn, 2007, pp. 1048–1049). The interconnected health and development needs of marginalized populations vulnerable to spatial dislocation have received little systematic attention (Kim, et al., 2013, p. 186). Health and development are inseparable. At the end of the 20th Century, the World Bank conducted a qualitative study in 60 countries that focused on poor people’s economic experiences and perspectives. To the surprise of researchers involved in the interviews and small-group discussions, health emerged as a critical issue. Of particular importance are findings that poor people “overwhelmingly link disease and ill-health to poverty” and that “good health is not only valued in its own right, but also because it is crucial to economic survival” (WHO and World Bank, 2005, p. 4). Illness constituted the most frequently cited cause of a downward slide into poverty and despair: Sickness of the family breadwinner is something that poor people particularly fear. It means food and income suddenly stop. Paying for treatment brings more impoverishment – assets may have to be sold and debts incurred. (WHO and World Bank, 2005, pp. 15–17) In One Illness Away, Anirudh Krishna (2010, pp. 157, 73, 76–77, 79, 87) documents the multiple cross-national situations where “poor health is not simply a

Introduction 5 Distinguishing major types of population movements allows us to analyze the multiple and diverse interfaces of mobility and health. Over a billion tourists cross one or more national borders annually (Mavroudi and Nagel, 2016, p. 8). In fiscal year 2011/2012, more than 65 million non-migrants entered the United States alone as temporary visitors for pleasure and/or business, temporary workers and families, students and exchange specialists, or diplomats (Satyen, et al., 2016, p. 489; also see Haines, 2017, pp. 64–66)10 at the same time that “60 million US citizens traveled overseas” (Mavroudi and Nagel, 2016, p. 8). Nearly “100 million people pass through British ports-of-entry each year” (Mavroudi and Nagel, 2016, p. 8). By 2012, some 4 million students traversed national borders (Chou, Kamola, and Pietsch, 2016, p. 5). Canada, a country that successfully encourages international students to become citizens, hosted more than 350,000 students from other countries (roughly 1 percent of its population) in the 2015/2016 school year (Smith, 2017). Transnational mobility also encompasses a substantial number of longerduration moves, or migrations.11 Roughly 3.3 percent of the world’s population are cross-border migrants (Connor, 2016). Most transnational migration follows South-South routes (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 8–9), although migrants are unevenly distributed on a nation-state basis (see Mavroudi and Nagel, 2016, pp. 9–11). Countries in Sub-Saharan Africa account for “eight of the ten fastest growing international migrant populations” (Connor, 2018).12 In absolute numbers, the United States has received more international migrants (46.6 million) than any other country (Connor, 2016). In aggregate terms, the proportion of international migrants to the total population increased from less than 9% in 2000 to 11% in 2013 in the developed countries, but has remained stable in developing countries (estimated at 2%) as a result of significant natural population growth and higher return levels. (Renzaho, 2016, p. 124) Applying a transnational migration perspective enables fully informed approaches to public policy and global health that “take into consideration the often transnational contexts that international migrants navigate” (Zhou, et al., 2017, p. 645). In most cases, mobility (and immobility) is “more or less voluntary or forced” (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 18 [emphasis added]; also Koser and Martin, 2011, p. 4). While typically determined by interacting elements of multiple and even offsetting considerations and conditioned by capacity to relocate, migration can be predominantly reactive or proactive. Although all migrations are the outcome of contextual interactions between human agency and structural forces beyond the immediate control of ordinary people . . ., it is also apparent that some migrations . . . are motivated more obviously by the immediate threat of violence and conflict than by economic interests. (Mavroudi and Nagel, 2016, p. 119; also Koehn, 1991)13

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According to the U.N. Secretary-General’s Report on Prevention and Control of Non-communicable Diseases (document A/66/83), “a vicious cycle is created by the [chronic disease] epidemic, whereby non-communicable diseases and their risk factors worsen poverty, while poverty results in rising rates of such diseases” (U.N., General Assembly, 2011).2 Fundamentally, then, sustainable development necessitates removing access barriers to health care (Suri, et al., 2013, pp. 257, 259, 261–263) – including integrated surgical care for injuries, cardiac diseases, childbirth, dental needs, and eye repair (Farmer, et al., 2013, pp. 329–331). At the same time, improved population-health outcomes in the South depend upon progress toward sustainable development.3

Southern health systems as drivers of and barriers to sustainable development For the South’s poor, common midstream social and economic determinants of health disparities are undernourishment, lack of access to safe water, absent or deficient sanitation, and unhygienic and overcrowded housing conditions (World Health Organization and World Bank, 2005, pp. 4, 6–8; McCracken and Phillips, 2017, p. 369). Needy public-health systems are confronting a serious shortage of skilled workers coincident with the South’s growing double burden of non-communicable and infectious diseases4 (Connell, 2010, pp. 12, 15–17, 19, 32–35; McCracken and Phillips, 2017, pp. 190, 192; Boseley and Davidson, 2015; Hyde and Higgs, 2016, p. 183). These public-health challenges compete with for-profit health-care providers, not-for-profit NGOs (Box 5.3), and other development-oriented sectors for scarce resources (Crisp, 2010, p. 77; Garrett, 2007, pp. 27–28, 35; Mackey and Liang, 2013, p. 2). Poor people living in rural and remote areas that are challenged to attract professional staff are particularly disadvantaged by the inequitable internal distribution of Southern health workers (Connell, 2010, pp. 20–23, 26–29, 35, 38; Renzaho, 2016, p. 153; Gerein, Green, and Pearson, 2006, p. 42). The outcome, consistent with the inverse care law (Box 5.4), is a less healthy national workforce.

Box 5.3 NGO code of conduct for health systems strengthening In an initiative intended to discourage NGOs “from poaching health workers from the already struggling public-health systems” in most Southern countries, by 2015 63 health-oriented organizations had signed the non-binding NGO Code of Conduct for Health Systems Strengthening. Source: Renzaho (2016, pp. 183–184)

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Box 5.4 Inverse care law “The availability of good medical care tends to vary inversely with the need for it in the population served.” Source: cited in Connell (2010, p. 18)

ERID impacts The SARS experience is both disquieting and instructive with regard to Southern health-care systems and sustainable-development prospects. SARS took a disproportionate toll of frontline health-care providers and forced the temporary closure of well-endowed hospitals in Hong Kong, Taipei, Beijing, and Toronto. In most poor countries, a comparable loss of life among an already insufficient and overstretched medical corps would be likely to devastate health-care systems for years. Immediately prior to the Ebola outbreak, “Liberia’s 4.3 million people were served by just 51 physicians – fewer than many clinical units in a typical major U.S. teaching hospital” (Boozary, Farmer, and Jha, 2014, p. 1859). More than 500 West African health workers perished during the Ebola outbreak of 2014–2015.5 The loss of “78, 83, and 79 doctors, nurses, and midwives from Guinea, Liberia, and Sierra Leone, respectively, probably led to somewhere in the order of a 75% increase in maternal mortality across the countries.” Further, cessation of usual care for malaria in 2014 as a result of the Ebola epidemic probably resulted in increases in untreated malaria cases of 45% in Guinea, 88% in Sierra Leone, and 140% in Liberia, and an additional 10,000 deaths. (Mullan, 2015) The SDGs and health system improvements Sustainability features in 11 of the 17 Sustainable Development Goals (SDGs); two others address poverty and inequality. Goal 3 encompasses healthy lives and well-being for all (McCracken and Phillips, 2017, p. 192). Increasingly, funding proposals for health initiatives in Africa need to be tied to the SDGs (Blair, 2018). Southern-health-system interventions that can drive sustainable development and promote well-being include training and employing local staff6 coupled with task shifting, purchasing locally produced supplies, and prioritizing preventative approaches. Other reinforcing basic-health-enhancing measures that also advance SDGs include improving nutritional standards, reducing exposure to hazardous working conditions, and adapting resource-conserving rather than capital-intensive innovations in multi-sector efforts to improve road transportation, housing conditions, water and electricity schemes, and urban and rural sanitation (Kim, et al., 2013, p. 194; Stevenson, 2016, pp. 125–126; Herrick and

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Reubi, 2017, p. xviii; Connell, 2010, p. 26; Diderichsen, Evans, and Whitehead, 2001, pp. 19–20; Koehn, 2007, p. 1064). The accompaniment foreign-assistance strategy for supporting global health initiatives in the South by redressing structural obstacles offers valuable guidelines for simultaneously advancing sustainable development (see Weigel, Basilico, and Farmer, 2013, pp. 294–296; Drobac, et al., 2013, pp. 133, 155–156, 160–161). Telemedicine and mobile devices can play a vital part in enabling health system breakthroughs in Southern countries and remote areas that are successful in “overcoming the present enormous global digital divide” in Internet access (McCracken and Phillips, 2017, p. 374). Moreover, bottom-up South-South initiatives, such as those supported by the Regional Network for Equity in Health in East and Southern Africa (EQUINET), advance self-reliance and health equity. EQUINET is “a network of professionals, civil society members, policy makers, state officials and others within the region who have come together as an equity catalyst to promote and realise shared values of equity and social justice in health.”7 Vertical versus horizontal approaches External partners in health and development initiatives debate the benefits of vertical versus horizontal approaches (see, for instance, Smith and MacKellar, 2007; Garrett, 2007, pp. 14–15, 23, 26, 37–38; Moran, 2009, pp. 121–122). Vertical-approach advocates “favor disease-specific interventions”8 and prioritization of immunization programs (Davies, 2010, pp. 181–182), while horizontal approach proponents “favor primary care improvements and investments in health systems” (Kim, et al., 2013, p. 198; Boozary, Farmer, and Jha, 2014, p. 1860). In some circumstances, well-designed vertical interventions with dedicated exit strategies strengthen Southern health systems (Crisp, 2010, p. 90). In Haiti, for instance, Partners In Health “used TB and AIDS efforts as a wedge to strengthen the local health system” (Kim, et al., 2013, p. 199).9 Beneficial horizontal initiatives are plentiful. Working in partnership with local and national governments in the South, the Clinton Health Access Initiative (CHAI) aims to enhance the capacity of public-sector health systems “by improving supply chain management, rural health infrastructure, laboratory systems, and training platforms for health care workers” (Kim, et al., 2013, p. 206; also Weigel, Basilico, and Farmer, 2013, pp. 294–295). The challenges of “reaching the last mile” are addressed by NGOs such as VillageReach.10 The Essential Health Benefit (EHB) approach widely implemented in East and southern Africa “is a policy intervention designed to direct resources to priority areas of health service delivery to reduce disease burdens and ensure equity in health” (Luwabelwa, et al., 2017, pp. 4, 2). Sharing existing health-delivery infrastructure provides further opportunities for all intervention-focused actors to promote efficiency and reduce costs (Kim, et al., 2013, pp. 192–194). Coordinating vertical and horizontal in-country NGO health-related and resilience-building activity and working on a cross-sector basis within national

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priorities for sustainable development are additional potential-realizing steps forward (Crisp, 2016, p. 190; Brown, 2016, pp. 91–92, 168; Kanth, Gleicher, and Guo, 2013, pp. 217, 219; Davies, 2010, pp. 181–182). The most comprehensive, albeit locationally limited, integrated approach to sustainable development is the Millennium Villages project. Millennium Villages aims to “address the root causes of extreme poverty by taking a holistic, community-led approach to sustainable development.”11 Strengthening village-health centers, training communityhealth workers, and supplying clean water and solar electricity constitute some of the integrated health-related projects with synergistic development potential that fall under the Millennium Villages’ umbrella.

Health, development, and return migration Circular-migration stressors can directly impact health conditions that adversely affect development in the South through the uncontained influence of “transnational disorders” that are “structurally produced and personally experienced within the borders of more than one country” (Duncan, 2014, pp. 24, 27, 34, 37; also Ullmann, Goldman, and Massey, 2011, p. 422). Given the rarity of provisions for cross-border care and record keeping, transnational disorders, which often include acute mental distress, are subject to competing interpretations, delay in presentation, confusing circumstances, community rejection, and partial and inferior treatment upon return to one’s country of origin (Duncan, 2014, pp. 25, 27–28, 35–37; also Gushulak, 2001a, p. 323). In many situations of return migration, therefore, protracted “suffering is transnationally shaped and transnationally felt by migrants and the family members who struggle to support them” (Duncan, 2014, p. 36; emphasis in original).12 Among migrants returning to the South, “lengthy residence in areas of low prevalence may reduce herd immunity to infections that are still prevalent in the area of origin” (Gushulak, 2001b, p. 266). At the same time, the return of migrants who acquired unfamiliar infectious diseases during the migration process poses special risks for communities of origin (WHO, 2010, p. 53). Specifically, “the cyclical movement of Latino migrant men between their countries of origin and U.S. destinations where HIV/STD prevalence rates are higher,” along with environmental conditions that elevate risk behaviors, are likely to “contribute to the spread of HIV infection to migrants’ wives and other sex partners in their home countries” (Painter, et al., 2012, p. 355; also Hirsch and Vasquez, 2012, pp. 103–104, 107). Although returning migrants who have accumulated wealth in the North can potentially translate this acquired resource into improved health outcomes for themselves over the long term, they are more likely than those who never leave the South to need to deal with contracted diseases of affluence (Ullmann, Goldman, and Massey, 2011, pp. 422, 424–426). Serving as positive agents of health promotion remains an untapped possibility for many returned migrants from Northern places (Ullmann, Goldman, and Massey, 2011, p. 426; Carrillo, 2012, pp. 48–49). Conditions surrounding refugee repatriation require special attention. To maximize prospects for successful repatriation that supports long-term sustainable

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development in the sending-country, refugee participation needs to be ensured at all stages of decision making regarding training and repatriation (Koehn, 1994b, p. 104; Koehn, 1991, p. 385). Health, education,13 and reintegration needs, identified through careful assessments that involve refugees themselves, should drive the planning and implementation of programs directed toward training healthsector personnel and promoting sustainable development in the sending country that commence at an early date in the dislocation experience (Koehn, 1994a, pp. 6–7, 83–85; Ruiz, 1994, p. 59; Martin, et al., 2017, p. 108). The special position of women in health care and the need to prepare community-health workers should receive attention in future-oriented training programs (Koehn, 1994a, pp. 73, 83–85; Ruiz, 1994, p. 60). The safe and durable voluntary repatriation of exile populations depends on the availability of key protections, including advance fact-finding visits by refugee representatives, human-rights guarantees, and “independent verification that the requisite changes have actually occurred” (Koehn, 1994b, p. 109; also Koehn, 1995). The underlying contributors to armed conflict and persecution must be removed if re-displacement is to be prevented (Martin, et al., 2017, p. 105). International donors must commit sufficient resources to support sustainabledevelopment projects that meet the basic needs of returnees along with equivalent opportunities for people residing in proximity who did not leave (Koehn, 1994b, pp. 109, 104). The forcible or voluntary return of large numbers of chronically ill migrants suffering from infectious or chronic illnesses to countries where health-care services are under-resourced is likely to reduce access by non-mobile inhabitants further and to impede sustainable-development initiatives. This situation occurred when persons chronically ill with renal failure, cancer, and heart disease returned en mass to the former Yugoslavia (Gushulak, 2001a, p. 324).14 On the plus side of the Southern ledger, Mexico’s hospitals mixtos (mixed hospitals) embrace services provided by traditional healers and trained cultural brokers. This progressive initiative helps ensure that “biomedical providers understand the cultural significance of migrants’ use of traditional medicine, as well as educating migrants on when accessing biomedical interventions may be in their best interest” (Gonzalez-Vazquez, Pelcastre-Villafuerte, and Taboada, 2016, p. 1196). Additional changes are called for, however. Similar to prevailing practice involving migrants residing in the North, Whitney Duncan (2014, p. 37) found that “practitioners in the United States and Oaxaca never collaborated to understand a [returned] migrant’s case.”15 In rural Northern Togo, in contrast, the dialogue between traditional healing and biomedicine is “already underway and constantly evolving” (Rotolo, 2016, p. 82; also pp. 68, 77; also see Chung, 2014, pp. 604–609).

Fatal flow of expertise The fatal-flow-of-expertise conundrum highlights the critical importance of transnational action in the global health and migration arenas along with the limitations of current governance arrangements. In the 1980s and 1990s, the structural-adjustment conditions imposed by the International Monetary Fund

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(IMF) and other global-finance agencies catalyzed reductions in public-sector workforces in the South, declining salaries, and massive out-migration by critically needed nurses and doctors (Connell, 2010, pp. 36–37; Crisp, 2010, p. 78). In the absence of national- and personal-development promise in terms of earnings, working conditions, and training opportunities, many Southern nurses, doctors, dentists, and allied-health workers such as laboratory technicians view international migration as their best opportunity to secure professionally fulfilling facilities and opportunities and favorable living conditions for themselves and their families (Connell, 2014, pp. 73, 75–77, 79–80; Crisp, 2010, pp. 69, 71; Healy and Oikelome, 2007, p. 1925). In some cases, such as nurses in India, the exit inclination is targeted and reinforced by multinational-corporate interests and globally oriented health-profession training (Walton-Roberts, 2015, p. 380). The perceived gains and losses of medical migration vary by level of analysis: individual, professional, national, and global. Each dimension is treated in sections that follow. Consequences for underserved Southern countries From the perspective of the underserved nation-state, health and development are severely disadvantaged by the out-migration of trained health-care professionals. Southern countries mired in poverty that “need human capital the most are among the main losers” from the South to North flight of skilled professionals (Renzaho, 2016, pp. 139–143). In comparison with African numbers, for instance, the United States averages about 12 times as many health-care workers per 1,000 inhabitants (Kim, et al., 2013, p. 206). More than half of all physicians trained in 11 Southern countries that face workforce shortages practice in Organization for Economic Co-operation and Development (OECD) countries (Taylor and Dhillon, 2012, p. 102). Approximately “one in three (30%) and one in four (25%) doctors trained in Ghana and Uganda respectively work in Canada and the USA” (Renzaho, 2016, p. 143; also pp. 144, 148). About three-quarters of Saudi Arabia’s nurses and doctors have emigrated from other countries (Crisp, 2010, p. 72). Personnel movements within the North can exacerbate the problem of Southern health-care deficiencies. For instance, middle-income Ireland’s health system has experienced large-scale physician out-migration (mainly to the UK, USA, Canada, Australia, and New Zealand) with recently declining levels of return migration. Ireland’s “failure to retain doctors has translated into heavy reliance on internationally trained doctors to staff the Irish health system” (Humphries, et al., forthcoming). Since the principal source countries where Ireland replenishes its departing physicians are places like Nigeria, Pakistan, and India, the resolution of Ireland’s workforce shortage occurs at the expense of further exodus from the South (ibid.). The continuing fatal flow of health expertise in Northern directions further constricts the limited availability of trained health workers and individual health care of all kinds in the South (see Crisp, 2010 , pp. 76–77; Garrett, 2007 ,

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pp. 15, 28; Kapur and McHale, 2005, pp. 28–29; Renzaho, 2016, pp. 147–148, 155–157; Mullan, 2006, pp. 380–382, 386–389; Gerein, Green, and Pearson, 2006, p. 46) at the same time that it increases the costs of trained-manpower losses16 and relieves pressures for health-system reform (Mullan, 2006, p. 389). Mental-health professionals are in particularly short supply (Becker, et al., 2013, p. 218). In Africa, “the emigration of healthcare professionals has limited the ability of public-health officials to contend with epidemic diseases and high rates of maternal and infant mortality” (Mavroudi and Nagel, 2016, p. 108; also Gerein, Green, and Pearson, 2006, pp. 40–42). Ironically, some Southeast Asian countries with robust medical-tourism industries or government-sponsored labor-export policies also fail to meet their own population’s health-care needs (Mackey and Liang, 2013, p. 2). Efforts to address Southern losses The 2010 nonbinding World Health Organization Global Code of Practice on the International Recruitment of Health Personnel (Renzaho, 2016, pp. 180–182) constitutes one international effort to address the fatal flow from South to North (also see Box 5.3). Allyn Taylor and Ibadat Dhillon (2012, pp. 103, 119–120) view the Code as a promising development. However, Tim Mackey and Bryan Liang (2013, pp. 3–4, 6) are less sanguine about the Code’s provisions and uptake; they present thoughtful alternative suggestions for providing a “safe, equitable, . . . efficient” and stronger transnational-collaborative pathway for employing Southern health-care workers in the North. Public-health-system strengthening offers one of the most promising ways to stem the South to North drain of health expertise (Kim, et al., 2013, p. 209; Crisp, 2010, p. 77; Mullan, 2006, pp. 390–391). In response to glaring NorthSouth disparities exacerbated by the fatal flow of expertise, some domestic and foreign-supported programs focus on training community-health workers17 and paraprofessionals in support of task-shifting initiatives aimed at offsetting the human-resource shortfalls, particularly in remote and underserved rural areas (Kim, et al., 2013, pp. 207–208; Connell, 2010, p. 35; Boozary, Farmer, and Jha, 2014, p. 1859; Crisp, 2010, pp. 80, 201; Sheikh and Afzal, 2012, p. 310; McCracken and Phillips, 2017, pp. 281–283; Crisp, 2016, pp. 192–193, 204; Frenk, et al., 2010, pp. 1947–1499; Mackey and Liang, 2013, pp. 2–3; Gerein, Green, and Pearson, 2006, p. 44).18 Basic-health workers can provide a wide range of critical primary-health-care services (see Frenk, et al., 2010, pp. 1947, 1951) and be employed in large numbers. For instance, more than three-fourths of Pakistan’s rural population are served by its 100,000-strong Lady Health Workers program (Frenk, et al., 2010, pp. 1947–1498). With a membership of more than 300 diverse and influential actors, the Global Health Workforce Alliance endeavors to redress the acute shortage of health workers in Southern contexts.19 The Alliance commenced providing catalytic funding to eight countries experiencing the most critical shortfalls – Angola, Benin, Cameroon, Ethiopia, Haiti, Sudan, Vietnam, and Zambia (Sheikh and

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Afzal, 2012, pp. 297, 305–309). For decades, the Government of Cuba has exported thousands of doctors to serve overseas in a bold South-South initiative (Frenk, et al., 2010, p. 1936; Fiddian-Qasmiyeh, 2015, p. 19; Crisp, 2016, p. 148) that has profoundly impacted underserved persons, resource-deprived communities, and medical education (Kerry, Auld, and Farmer, 2010, p. 1200).20 By 2017, for instance, about 18,000 Cuban physicians had provided primary care in remote and impoverished areas of Brazil, reaching indigenous communities and helping to lower infant-mortality rates (Londono, 2017, p. A10).21 Cuba also has been active in providing Sahrawi, Palestinian, and other refugees with scholarship assistance that enables undertaking participant-influenced training as educational migrants; in some cases, beneficiaries have practiced medicine in Spain or upon return to a refugee camp (Fiddian-Qasmiyeh, 2015, pp. 1–2, 5, 7, 13, 19, 22–23).

Circular migration and diasporic contributions to global health and sustainable development In certain circumstances,22 emigration “can actually amplify the domestic [sendingcountry] voice of groups that exit” (Kapur, 2010, p. 42; emphasis in original). For instance, Northern aid agencies and NGOs increasingly view diasporas as fertile sources of expertise on sustainable-development undertakings in the South (Mavroudi and Nagel, 2016, pp. 106–107; Newland, 2010, p. 23).23 As insightfully articulated by the Zimbabwe-trained physician Pride Chigwedere, the key measure “is not where you are, but what you are doing for Africa” (cited in Madamombe, 2006, 16). In a historic advance from the Millennium Development Goals (MDGs), U.N. members integrated “the role of migrants, their communities and diasporas” into the Sustainable Development Goals (SDGs) adopted at the 2015 Sustainable Development Summit (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 95). The sum of remittances sent home by emigrants exceeds total foreign aid to Southern countries (Crisp, 2010, p. 70; Hossain, Khan, and Short, 2017, p. 2; also see Edjang, 2016, p. 179) and studies suggest that “the effect of remittances in stimulating the economy is six to seven times higher than that of foreign aid” (Renzaho, 2016, p. 177). In places, individual, and collective remittances from migrants residing in the North generate “increased spending on health, education, and nutrition” that promotes family and community well-being and productivity, while donated equipment, transnational partnerships, and technology transfers support sending-country health-care systems (Renzaho, 2016, pp. 159–161; also Marini, 2015, pp. 35–36, 40–44; Lindley and Hammond, 2014, pp. 56, 61; Nwadiuko, et al., 2016). However, “the benefits of emigration and remittances . . . are not evenly distributed socially or geographically, and emigration tends to exacerbate, rather than to alleviate, uneven [and unequal] patterns of development” (Mavroudi and Nagel, 2016, p. 107; also Pires, 2015, p. 72). Further, emigration circumvents the need to address structural contributors to underdevelopment and individual

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remittances often are directed toward personal consumption by family members (e.g., the construction of palatial homes) rather than sustainable communitybased development projects (Mavroudi and Nagel, 2016, pp. 108, 110). Tapping into transnationally enhanced professional synergies Nevertheless, there are valuable potential benefits associated with today’s flourishing circular migration in terms of health and sustainable-development initiatives in the South. Contemporary connectedness, Calestous Juma maintains, requires jettisoning the “old-fashioned metaphor of the ‘brain drain.’” The forward-oriented challenge “is figuring out how to tap the expertise of those who migrate and upgrade their skills while in the diaspora, not engaging in futile efforts to stall international migration” (Juma, 2005, pp. 18–19; also Renzaho, 2016, pp. 138, 188) nor contributing to “brain waste.”24 The Global Commission on International Migration established by U.N. Secretary-General Kofi Annan reached a similar conclusion based on two years of study (see GCIM, 2005, 31).25 Brain flow can be arranged to benefit both sending and receiving countries. In addition, transnational social fields (Pitkanen and Kalekin-Fishman, 2007, pp. 1, 3; Vertovec, 2009, p. 77) offer diaspora professionals the chance to expand and deepen their own “opportunity space” (Tarrow, 2005, p. 25) without sacrificing the resources available at their current place. Transmigrant professionals are plugged in to elaborate formal and informal transnational social networks built upon interpersonal bonds of trust with colleagues and communities. They operate personally and collectively, and physically and virtually, across nation-state borders. Even without returning, moreover, diasporic professionals in the North are positioned to “call attention to issues of interest in their home countries” through public-relations campaigns, political advocacy, social and internet networks, and fund-raising appeals (Kapur, 2010, p. 38; also Yin and Koehn, 2011; Newland, 2010, p. 10). Whether the issue be ameliorating poverty, addressing climatic change (see Koehn, 2006), combating the spread of HIV/AIDS (Connell, 2010, p. 16), enhancing sustainable development, or expanding water quantity and safe drinkability, it is crucial that we secure the insights and apply the expertise of our transmigrant sisters and brothers. With proven skill portability, bicultural and multicultural individuals have a head start on transnational competence that endows them with valuable personal assets for contributing in today’s socially, politically, economically, culturally, technologically, and environmentally interconnected professional-opportunity spaces (Vertovec and Rogers, 1998, pp. 6–9; Marini, 2015, p. 43; Nwadiuko, et al., 2016; Carr, Inkson, and Thorn, 2005, p. 388; Terrazas, 2010, pp. 168, 170, 207). Transmigrants often possess valuable process expertise – critical awareness of sending-country political culture, bureaucratic rules, the history of conflicts and coalitions, likely sources of support and resistance – and astuteness in translating and fitting insights garnered abroad in ways that are compelling domestically. In

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addition, committed diasporic volunteers bring “deep understanding of on-theground needs” (Terrazas, 2010, p. 169). Finally, circular-migrating diasporic professionals are uniquely positioned to identify opportunities for reverse innovation and carry them back to the North (Crisp, 2010, pp. 191, 202). Reverse innovation finds ways to apply sustainable methods and tools found useful in the South to health challenges “faced in places of greater abundance” (Farmer, et al., 2013, p. 336). These opportunities can be promoted by increased support for refugee- and diaspora-led organizations (Martin, et al., 2017, p. 112). However, it also is important to recognize that many diaspora professionals have been practicing in situations that are radically different from conditions that prevail in the sending-country. Further, “transstate activists who do not permanently reside in the community of origin may hold very different notions of development from those ‘at home’” (Faist, 2008, p. 77; also Lindley and Hammond, 2014, p. 61). Diaspora returnees on health and development assignments in the ancestral country can be distracted by personal or family concerns (Terrazas, 2010, p. 170). Regrettably, moreover, professional-education programs around the world are particularly deficient in anticipating challenges brought about by circular-migration life trajectories and in preparing graduates to be effective nation-state transcenders (Cortes and Wilkinson, 2009, p. 21). Facilitating circular-migration contributions When diaspora professionals are called upon to transform intruding distant complexities into locally contextualized actions and products, the most relevant interactions and experiences are simultaneously face-to-face and deterritorialized. While cyberspace is useful for engaging disparate professionals in shallow encounters, it also offers “an escape from many of the difficulties of deeper more involved human relations” (Shaules, 2007, p. 14). It is vital, therefore, that compelling material and nonmaterial incentives be mobilized that will encourage short-term and long-term return migration by health-care workers and other diaspora professionals who possess skills that can contribute to health promotion (Renzaho, 2016, pp. 162–163, 189; Mackey and Liang, 2013, p. 3; Healy and Oikelome, 2007, p. 1925; Gerein, Green, and Pearson, 2006, p. 47). At the national level, for instance, the Nigerian Federal Government’s Linkage with Experts and Academics in the Diaspora Scheme (LEADS) supports diaspora scholars of Nigerian origin with expertise in various fields, including medicine, in short-term visiting appointments to teach, conduct research, and engage in community-service activities at Nigerian universities.26 In addition, through an agreement with the Association of Nigerian Physicians in the Americas (ANPA) and the Nigerian Universities Commission, the Nigerian Ministry of Health facilitated diasporic participation in an overhaul of Nigeria’s medical-education curriculum (Nwadiuko, et al., 2016). In their survey of 156 U.S.-based Nigerian physicians, Joseph Nwadiuko and colleagues (2016) found that “fifty-five percent of respondents expressed at least a moderate desire to re-emigrate to Nigeria to

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practice medicine, and 45% indicated it was ‘very likely’ or ‘likely’ that they would do so.” In fact, “one respondent was in the process of building a diagnostic center in Nigeria he planned to run full time.” The mean age of those indicating a moderate to high likelihood of return (51) suggests that returnees would “carry a premium of experience, professional contacts, and potential productive years” (Nwadiuko, et al., 2016). However, few nation-sponsored return programs in the South “have succeeded in encouraging large-scale or sustained return of the highly skilled” (Kapur and McHale, 2005, p. 201). On an international scale, UNDP’s Transfer of Knowledge through Expatriate Nationals (TOKTEN) program and IOM’s Migration for Development in Africa program serve as models for “transfers of expertise between diasporas and their countries of origin” that have “helped to highlight the value of the initiatives of individuals seeking to support development efforts in their native countries” (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 76). Reports on the impact of TOKTEN and IOM participants generally have been positive, albeit limited in scope and duration (Kapur and McHale, 2005, p. 200; Renzaho, 2016, pp. 175–176; Terrazas, 2010, pp. 184–187). According to a Rwanda evaluation, for instance, “the programme attracted 47 [highly motivated] Rwandan expatriates with high levels of education and training in science, technology, agricultural, and health fields” (Mavroudi and Nagel, 2016, p. 106). With nearly US$1 million in support from Italy, the Africa Diaspora Programme aims to strengthen the capacity of Ethiopia’s health system to deliver health services by “engaging, deploying, and utilising Ethiopian professionals in the area of neurology, tele-medicine and social work” (Renzaho, 2016, pp. 176–177). Special efforts are needed to facilitate the circular “talent flow” (Carr, Inkson, and Thorn, 2005, pp. 387–388) of transnationally competent specialists if low-income countries are to build current and future transnational social capital (MacRae and Wight, 2006, 218–219) and take advantage of this promising path along the road to domestic and global sustainability.27 Bringing the diaspora back in on sustainability initiatives requires a conducive infrastructure – people, policy, processes, and technology (MacRae and Wight, 2006, p. 215). The key issue for diaspora professionals, in Abraham Weisblat’s words (1993, p. 184), “is whether there is an opportunity to use their acquired skills upon their return” – for the benefit of the country of origin (Koehn, 1991, p. 385; also Nwadiuko, et al., 2016). At minimum, a conducive sending-country opportunity space for tapping into diasporic capabilities requires welcoming attitudes, transnational connectivity, adequate research and teaching facilities (Ackah, 2008, p. 40), reasoned and transparent decision making, and bureaucratic support rather than hindrance (Connell, 2010, p. 22). For new and “encore” diaspora professionals to engage meaningfully and contribute effectively in sending lands, higher-education approaches and contextual training need to build on the technical and interpersonal strengths and address the skill limitations of transmigrants. For instance, clinical education for diaspora professionals would emphasize cross-border ethnographic research, uncovering transstate and local sources of health inequities and obstacles, exploring and

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aligning indigenous and biomedical beliefs and agency in a nuanced and dynamic manner, valuing core clinical functions of indigenous-health care, and engaging in patient advocacy aimed at overcoming disparities rooted in the institutional, political, legal, and socio-economic-context barriers to health that confront physically and virtually mobile patients. The transnational-competence (TC) framework for professional higher education elaborated in Chapter 4 offers a promising pathway for achieving these objectives. We are rapidly approaching the time when all professionals will be virtually and physically mobile circular migrants connected by vibrant and dense networks that span borders. Higher-education institutions in North and South can contribute in decisive ways to advancing the preparation of professionals, including diaspora professionals, for participation in promoting global health and sustainable development. Through comprehensive TC-informed and migration-tailored curriculums along with valued Southern incentives, professional programs in multiple fields can graduate practitioners from the diaspora who are prepared to return and equipped with the analytic, emotional, creative, communicative, and operational skills needed to tackle tomorrow’s transboundary health and sustainability challenges. We will return to this theme in Chapter 8.

Linking transmigration with health and sustainable development This chapter has explored health and migration connections through the lens of sustainable-development challenges in poor countries. Improving health in Southern contexts requires simultaneous action on multiple fronts (Crisp, 2010, pp. 200, 204) and across multiple sectors (Kickbusch, 2015; Jamison, et al., 2013, p. 1901). Efforts to address infectious and communicable disease and to overcome poverty need to be undertaken in concert. As a Lancet Commission proposed in 2013, substantial increases in international and national funding for health research and interventions aimed at diseases that disproportionately affect Southern countries would produce “enormous payoffs” in terms of mortality reductions and sustainable economic development (Jamison, et al., 2013, pp. 1898–1899). Transmigration offers a particularly promising vehicle for progress on Southern health and development challenges. Engaging the diaspora in a substantial way merits further attention and encouragement. These prospects are treated in depth in the concluding chapter.

Notes 1 HIV/AIDS proved especially disruptive with respect to the delivery of health, education, and agricultural services in Africa due to high rates of sickness and death among government personnel at all levels (Topouzis, 2004, p. 10). 2 In Kenya, for instance, an estimated “1.48 million people have been pushed far below the national poverty line by unexpected health expenditure” (Edjang, 2016, p. 170). On the structural conditions that contribute to the connection of alcohol consumption to health setbacks and economic and social losses in South Africa, see Herrick (2017).

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3 As Juha Uitto and Rajib Shaw (2016, p. 1) show, sustainable development also is intrinsically connected to migration tendencies associated with disasters and to approaches that reduce the risk of disasters and forced population movements. 4 Including neglected and widespread tropical diseases (NTDs) (McCracken and Phillips, 2017, pp. 194–196). 5 In spite of the continental-wide shortage of health workers, the African Union, “with financial support from the African Development Bank and African philanthropists,” mobilized more than 800 risk-accepting health personnel from 18 countries for service in Liberia, Guinea, and Sierra Leone during the Ebola outbreak (Edjang, 2016, p. 176). 6 The generation of subnational health-care employment exerts a “growth-inducing effect on other sectors” and provides expanded opportunities for women “due to the trend of feminization of the health workforce” (WHO, 2016, #39, #56). 7 EQUINET Africa. www.equinetafrica.org/; accessed 28 November 2017. Also see Sheikh, et al. (2016, p. 4). 8 For brief descriptions of four prominent examples (UNAIDS; Global Fund for AIDS, TB, and Malaria; Roll Back Malaria Partnership; and the Partnership for Maternal, New Born and Child Health), see Crisp (2016, p. 163). 9 For a contrasting viewpoint, see Garrett (2007, pp23–24). 10 See http://162.219.73.99/Cablecast/public-site/index.html#/show/6895?channel=1. 11 Millennium Villages. “Sector Strategy.” http://millenniumvillages.org/about/sectorstrategy/; accessed 29 April 2018. 12 In order to improve migrant health, therefore, it is necessary to incorporate “transnational perspectives into health research and the development of public health policies and programs for this population” (Villa-Torres, et al., 2017, p. 78). 13 Susan Martin and colleagues (2017, p. 112) find that “greater emphasis on livelihoods and education, with the concomitant funding needed to support such initiatives, could help dispel both the perception and the reality of hopelessness for many who are unable to return home or be resettled elsewhere.” 14 In the case of elderly dual citizens who resettle in Taiwan upon retirement primarily to access public-health care (and pursue an improved later life) at little personal cost, many non-mobile Taiwanese people resent the drain returnees place on the system without having contributed through taxes (Sun, 2014). Frail and ill U.S. retirees also relocate in Mexico in order to take advantage of the country’s medical services (Sunil, 2007). 15 For the WHO’s list of risks associated with the use of traditional and complementary health practices, see McCracken and Phillips (2017, p. 280). 16 Turn-of-the-century estimates indicate that Africa had lost more than US$2 billion in investments on physicians working abroad. In addition, “the continent spends approximately $4 billion to meet the salary of 100,000 western expatriates performing generic technical assistance tasks” (Renzhao, 2016, pp. 155, 157–158; also Nwadiuko, et al., 2016). 17 For an innovative approach to training community-mental-health workers, see Newnham (2017). 18 Expanding task shifting to include “delegation to family members” also can bring about positive health outcomes (Mackey and Liang, 2013, p. 2). 19 For related initiatives and approaches, including the World Bank’s Africa Diaspora Programme, see Renzaho (2016, pp. 174–176). 20 On the global distribution of medical schools, which “does not correspond well to either country population size or national disease burden,” see Frenk et al. (2010, pp. 1934–1937, 1949). 21 Recently, some Cuban doctors have objected to the terms of their contracts, which pay about one-fourth of the $3,620 a month that Brazil pays Cuba for each doctor (Londono, 2017). 22 The reasons why professionals leave their homelands and sending-country developments following departure are critical considerations in connection with diasporic-return

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possibilities. Devesh Kapur (2010, p. 43) notes that “The relative importance of political and economic factors underlying migration decisions will affect the nature and intensity of engagement with the country of origin after departure” (also see Yin and Koehn, 2011, p. 96; Koehn, 1991, pp. 366–368, 374). For instance, of the more than three million Nigerians living in the United States alone in 2004, “some 174,000 were information technology professionals, 202,000 were medical and allied professionals, about 50,000 were engineers, and another 250,000 were professionals in other areas, including university lecturers” (Jibril and Obaje, 2008, p. 362; also see Cahill, 2017, pp. 23–24). Brain, or talent, waste for both sending and receiving countries occurs when migranthealth professionals are unemployed, underemployed, and unused in destination places (Mackey and Liang, 2013, p. 2; Carr, Inkson, and Thorn, 2005, p. 390, Chapter 4). Missing in contemporary academic discourse, however, is space reserved for amplifying the potential path-breaking contributions that the diaspora professional can bring to sustainability and sustainable-development initiatives. National Universities Commission, http://nuc.edu.ng/?s=Linkage+with+Experts+and+ Academics+in+the+Diaspora+Scheme+%28LEADS%29+; accessed 19 November 2017. See, for instance, the Volunteer Health Corps initiative sponsored by the HIV/AIDS Twinning Center of the American International Health Alliance in partnership with the Network of Ethiopian Professionals in the Diaspora and the U.K. Volunteer Service Overseas program (Terrazas, 2010, pp. 176–178; 196–199).

References Ackah, Kofi (chief rapporteur). 2008. Developing and Retaining the Next Generation of Academics: Report of the Second University Leaders’ Forum Held in Accra, Ghana, 22–25 November. New York: Partnership for Higher Education in Africa. Baidawi, Adam. 2017. “A Surgeon Returns Home to Iraq to Help War’s Amputees.” New York Times, 29 July, p. A7. Becker, Anne; Motgi, Anjali; Weigel, Jonathan; Raviola, Giuseppe; Keshavjee, Salmaan; and Kleinman, Arthur. 2013. “The Unique Challenges of Mental Health and MDRTB.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 212–244. Blair, Martin E. 2018. “Building Inclusive Education Opportunities for Kenyan Children Who Are Deaf/Blind.” Presentation at the Global Public Health 2018 Lecture Series, University of Montana, Missoula. 21 February. http://hs.umt.edu/globalpublichealth/ lecture-series/default.php Boozary, Andrew S.; Farmer, Paul E.; and Jha, Ashish K. 2014. “The Ebola Outbreak, Fragile Health Systems, and Quality as a Cure.” JAMA 312, No. 18 (12 November):1859–1860. Boseley, Sarah; and Davidson, Helen. 2015. “Global Obesity Rise Puts UN Goals on DietRelated Diseases ‘Beyond Reach’.” Guardian, 9 October. Brown, Katrina. 2016. Resilience, Development and Global Change. London: Routledge. Cahill, Kevin M. 2017. Milestones in Humanitarian Action. New York: Fordham University Press. Carr, Stuart C.; Inkson, Kerr; and Thorn, Kaye. 2005. “From Global Careers to Talent Flow: Reinterpreting ‘Brain Drain’.” Journal of World Business 40:386–398. Carrillo, Hector. 2012. “Sexual Culture, Structure, and Change.” In HIV Prevention with Latinos: Theory, Research, and Practice, edited by Kurt C. Organista. Oxford: Oxford University Press. Pp. 41–61.

Migration, health, and development

165

Chung, Vincent C.H. 2014. “Conceptualizing the Integration of Traditional and Complementary Medicine in Health Systems: Patients, Policies, Professions and Providers.” In Routledge Handbook of Global Public Health in Asia, edited by Sian M. Griffiths, Jin Ling Tang, and Eng Kiong Yeoh. London: Routledge. Pp. 601–612. Connell, John. 2010. Migration and the Globalisation of Health Care: The Health Worker Exodus? Cheltenham, UK: Edward Elgar. Connell, John. 2014. “The Two Cultures of Health Worker Migration: A Pacific Perspective.” Social Science and Medicine 116:73–81. Cortes, Carlos E.; and Wilkinson, Louise C. 2009. “Developing and Implementing a Multicultural Vision.” In Contemporary Leadership and Intercultural Competence: Exploring the Cross-Cultural Dynamics within Organizations, edited by Michael A. Moodian. Los Angeles: Sage. Pp. 17–31. Crisp, Nigel. 2010. Turning the World Upside Down: The Search for Global Health in the 21st Century. London: Royal Society of Medicine Press. Crisp, Nigel. 2016. One World Health: An Overview of Global Health. Boca Raton, FL: CRC Press. Davies, Sara. 2010. Global Politics of Health. Cambridge, UK: Polity Press. Diderichsen, Finn; Evans, Timothy; and Whitehead, Margaret. 2001. “The Social Basis of Disparities in Health.” In Challenging Inequities in Health: From Ethics to Action, edited by Timothy Evans, Margaret Whitehead, Finn Diderichsen, Abbas Bhuiya, and Meg Wirth. Oxford: Oxford University Press. Pp. 13–23. Drobac, Peter; Basilico, Matthew; Messac, Luke; Walton, David; and Farmer, Paul. 2013. “Building an Effective Rural Health Delivery Model in Haiti and Rwanda.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 133–183. Duncan, Whitney L. 2014. “Transnational Disorders: Returned Migrants at Oaxaca’s Psychiatric Hospital.” Medical Anthropology Quarterly 29 (1):24–41. Edjang, Susana. 2016. “Sub-Saharan Africa: Escaping from Dependency.” In One World Health: An Overview of Global Health, edited by Nigel Crisp. Boca Raton, FL: CRC Press. Pp. 169–182. Faist, Thomas. 2008. “Transstate Spaces and Development: Some Critical Remarks.” In Rethinking Transnationalism: The Meso-Link of Organizations, edited by Ludger Pries. London: Routledge. Pp. 62–79. Farmer, Paul; Basilico, Matthew; Kerry, Vanessa; Ballard, Madeleine; Becker, Anne; Bukhman, Gene; Dahl, Ophelia; Ellner, Andy; Ivers, Louise; Jones, David; Meara, John; Mukherjee, Joia; Sievers, Amy; and Yamamoto, Alyssa. 2013. “Global Health Priorities for the Early Twenty-First Century.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 302–339. Fiddian-Qasmiyeh, Elena. 2015. South-South Educational Migration, Humanitarianism and Development: Views from the Caribbean, North Africa and the Middle East. London: Routledge. Frenk, Julio; Chen, Lincoln; Bhutta, Zulfiqar A.; Cohen, Jordan; Crisp, Nigel; Evans, Timothy; Fineberg, Harvey; Garcia, Patricia; Ke, Yang; Kelley, Patrick; Kistnasamy, Barry; Meleis, Afaf; Naylor, David; Pablos-Mendez, Ariel; Reddy, Srinath; Scrimshaw, Susan; Sepulveda, Jaime; Serwadda, David; and Zurayk, Huda, et al. 2010. “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World.” Lancet 376 (4 December):1923–1958. Garrett, Laurie. 2007. “The Challenge of Global Health.” Foreign Affairs 86 (1):14–38.

166

Migration, health, and development

Gerein, Nancy; Green, Andrew; and Pearson, Stephen. 2006. “The Implications of Shortages of Health Professionals for Maternal Health in Sub-Saharan Africa.” Reproductive Health Matters 14 (27):40–50. Global Commission on International Migration [GCIM]. 2005. Migration in an Interconnected World: New Directions for Action. Geneva: GCIM. Gonzalez-Vazquez, Tonatiuh T.; Pelcastre-Villafuerte, Blanca E.; and Taboada, Arianna. 2016. “Surviving the Distance: The Transnational Utilization of Traditional Medicine among Oaxacan Migrants in the US.” Journal of Immigrant and Minority Health 18:1190–1198. Gushulak, Brian. 2001a. “An Overview of the Health Aspects of Return in the Immigration Context.” In Health, Migration and Return: A Handbook for a Multidisciplinary Approach, edited by Peter J. van Krieken. The Hague: T.M.C. Asser Press. Pp. 315–325. Gushulak, Brian. 2001b. “Health Determinants in Migrants: The Impact of Population Mobility on Health.” In Health, Migration and Return: A Handbook for a Multidisciplinary Approach, edited by Peter J. van Krieken. The Hague: T.M.C. Asser Press. Pp. 255–268. Healy, Geraldine; and Oikelome, Franklin. 2007. “A Global Link between National Diversity and Policies? The Case of the Migration of Nigerian Physicians to the UK and USA.” Journal of Human Resource Management 18, No. 11 (November):1917–1933. Herrick, Clare. 2017. “Structural Violence, Capabilities and the Experiential Politics of Alcohol Regulation.” In Global Health and Geographical Imaginaries, edited by Clare Herrick and David Reubi. London: Routledge. Pp. 216–230. Herrick, Clare; and Reubi, David. 2017. “Introduction.” In Global Health and Geographical Imaginaries, edited by Clare Herrick and David Reubi. London: Routledge. Pp. vii–xxviii. Hirsch, Jennifer S.; and Vasquez, Emily. 2012. “Mexico-U.S. Migration, Social Exclusion, and HIV Risk: Multisectoral Approaches to Understanding and Preventing Infection.” In HIV Prevention with Latinos: Theory, Research, and Practice, edited by Kurt C. Organista. Oxford: Oxford University Press. Pp. 103–120. Hossain, Moazzem; Khan, M. Adil; and Short, Patricia. 2017. “An Overview of SouthSouth Migration: Opportunities, Risks and Policies.” In South-South Migration: Emerging Patterns, Opportunities and Risks, edited by Patricia Short, Moazzem Hossain, and M. Adil Khan. London: Routledge. Pp. 1–10. Huang, Yanzhong. 2009. “In-Flew-Enza: Pandemic Influenza and Its Security Implications.” In Innovation in Global Health Governance: Critical Cases, edited by Andrew F. Cooper and John J. Kirton. Burlington, VT: Ashgate. Pp. 129–152. Humphries, Niamh; Crowe, Sophie; McDermott, Cian; McAleese, Sara; and Brugha, Ruairi. Forthcoming. “The Consequences of Ireland’s Culture of Medical Migration.” Human Resources for Health. Hyde, Martin; and Higgs, Paul. 2016. Ageing and Globalisation. Bristol, UK: Polity Press. Ionesco, Dina; Mokhnacheva, Daria; and Gemenne, Francois. 2017. The Atlas of Environmental Migration. London: Routledge. Jamison, Dean T.; and 24 co-authors. 2013. “Global Health 2035: A World Converging within a Generation.” Lancet 382:1898–1955. Janes, Craig R.; Chuluundorj, O.; Hilliard, C.E.; Rak, K.; and Janchiv, Khulan. 2006. “Poor Medicine for Poor People? Assessing the Impact of Neoliberal Reform on Health Care Equity in a Post-Socialist Context.” Global Public Health 1:5–30. Jibril, Munzali; and Obaje, Abdulkarim. 2008. “Nigeria.” In Higher Education in Africa: The International Dimension, edited by Damtew Teferra and Jane Knight. Chestnut Hill, MA: Enter for International Higher Education, Boston College. Pp. 339–367.

Migration, health, and development

167

Juma, Calestous. 2005. “Reinventing Growth.” In Going for Growth: Science, Technology and Innovation in Africa, edited by Calestous Juma. London: Smith Institute. Pp. 10–23. Kanth, Priyanka; Gleicher, David; and Guo, Yan. 2013. “National Strategies for Global Health.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 285–303. Kapur, Devesh. 2010. Diaspora, Development, and Democracy: The Domestic Impact of International Migration from India. Oxford: Oxford University Press. Kapur, Devesh; and McHale, John. 2005. Give Us Your Best and Brightest: The Global Hunt for Talent and Its Impact on the Developing World. Washington, DC: Center for Global Development. Kerry, Vanessa B.; Auld, Sara; and Farmer, Paul. 2010. “An International Service Corp for Health: An Unconventional Prescription for Diplomacy.” New England Journal of Medicine 363 (13):1199–1202. Kickbusch, Ilona. 2015. “The Political Determinants of Health–10 Years on.” British Medical Journal 350:h81. Kim, Jim Yong; Porter, Michael; Rhatigan, Joseph; Weintraub, Rebecca; Basilico, Matthew; Van Der Hoof Holstein, Cassia; and Farmer, Paul. 2013. “Scaling Up Effective Delivery Models Worldwide.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 184–211. Koehn, Peter H. 1991. Refugees from Revolution: U.S. Policy and Third-World Migration. Boulder, CO: Westview Press. Koehn, Peter H. 1994a. Final Report of the International Symposium “Refugees and Development Assistance: Training for Voluntary Repatriation”. Missoula: Office of International Programs, The University of Montana, April. Koehn, Peter H. 1994b. “Refugee Settlement and Repatriation in Africa: Development Prospects and Constraints.” In African Refugees: Development Aid and Repatriation, edited by Howard Adelman and John Sorenson. Boulder, CO: Westview Press. Pp. 97–116. Koehn, Peter H. 1995. “Repatriation of African Exiles: The Decision to Return.” In Cambridge Survey of World Migration, edited by Robin Cohen. Cambridge: Cambridge University Press. Pp. 347–352. Koehn, Peter H. 2006. “Fitting a Vital Linkage Piece into the Multidimensional EmissionsReduction Puzzle: Nongovernmental Pathways to Consumption Changes in the PRC and the USA.” Climatic Change 77:377–413. Koehn, Peter H. 2007. “Global Health and Human Rights: Challenges for Public-Health Administrators in an Era of Interdependence and Mobility.” In Handbook of Globalization, Governance, and Public Administration, edited by Ali Farazmand and Jack Pinkowski. Boca Raton, FL: CRC Press. Pp. 1045–1073. Krishna, Anirudh. 2010. One Illness Away: Why People Become Poor and How They Escape Poverty. Oxford: Oxford University Press. Lindley, Anna; and Hammond, Laura. 2014. “Histories and Contemporary Challenges of Crisis and Mobility in Somalia.” In Crisis and Migration: Critical Perspectives, edited by Anna Lindley. London: Routledge. Pp. 46–72. Londono, Ernesto. 2017. “‘Slave Labor’: Cuban Doctors Rebel in Brazil.” New York Times, 29 September, pp. A1, A10. Luwabelwa, Mubita; Banda, Patrick; Palale, Muunda; and Chama-Chiliba, Chitalu. 2017. A Case Study of the Role of an Essential Health Benefit in the Delivery of Integrated

168

Migration, health, and development

Health Services in Zambia. EQUINET Discussion Paper 111, August. Harare, Zimbabwe: EQUINET. Mackey, Tim K.; and Liang, Bryan A. 2013. “Restructuring Brain Drain: Strengthening Governance and Financing for Health Worker Migration.” Global Health Action 6 (19923). MacLean, Sandra J.; and Brown, Sherri A. 2009. “Introduction: The Social Determinants of Global Health: Confronting Inequities.” In Health for Some: The Political Economy of Global Health Governance, edited by Sandra J. MacLean, Sherri A. Brown, and Pieter Fourie. New York: Palgrave Macmillan. Pp. 3–17. MacRae, Mairi; and Wight, Martin. 2006. “A Model Diaspora Network: The Origin and Evolution of Globalscot.” In Diaspora Networks and the International Migration of Skills: How Countries Can Draw on Their Talent Abroad, edited by Yevgeny Kuznetsov. Washington, DC: World Bank. Pp. 201–220. Madamombe, Itai. 2006. “Traditional Healers Boost Primary Health Care: Reaching Patients Missed by Modern Medicine.” Africa Renewal (January):10–11, 21. Marini, Francesco. 2015. “Immigrants and Transnational Engagement in the Diaspora: Ghanaian Associations in Italy and the UK.” In Africans on the Move: Migration, Diaspora and Development Nexus, edited by Fassil Demissie. London: Routledge. Pp. 33–46. Martin, Susan F.; Davis, Rochelle; Benton, Grace; and Waliany, Zoya. 2017. “Responsibility Sharing for Refugees in the Middle East and North Africa: Perspectives from Policymakers, Stakeholders, Refugees and Internally Displaced Persons.” Report 2017:8. Stockholm: Delmi, The Migration Studies Delegation. Mavroudi, Elizabeth; and Nagel, Caroline. 2016. Global Migration: Patterns, Processes, and Politics. London: Routledge. McCracken, Kevin; and Phillips, David R. 2017. Global Health: An Introduction to Current and Future Trends. London: Routledge. Moran, Michael. 2009. “Philanthropic Foundations and Global Health Partnership Formation: The Rockefeller Foundation and IAVI.” In Health for Some: The Political Economy of Global Health Governance, edited by Sandra J. MacLean, Sherri A. Brown, and Pieter Fourie. New York: Palgrave Macmillan. Pp. 118–129. Mullan, Fitzhugh. 2006. “Doctors for the World: Indian Physician Emigration.” Health Affairs 25 (2):380–393. Mullan, Zoe. 2015. “The Cost of Ebola.” Lancet Global Health 3 (8):e423. Newland, Kathleen. 2010. “Six Studies and a Road Map: Diasporas as Partners in Development.” In Diasporas: New Partners in Global Development Policy, edited by Kathleen Newland. Washington, DC: Migration Policy Institute. Pp. 1–24. Newnham, Elizabeth A. 2017. “Collaborative Training of Community Mental Health Workers.” In Public Health Humanitarian Responses to Natural Disasters, edited by Emily Ying Yang Chan. London: Routledge. Pp. 218–219. Nwadiuko, Joseph; James, Keyonie; Switzer, Galen E.; and Stern, Jamie. 2016. “Giving Back: A Mixed Methods Study of the Contributions of US-Based Nigerian Physicians to Home Country Health Systems.” Globalization and Health 12:33. Omaswa, Francis; and Crisp, Nigel. 2014. “Introduction to Part I: Overview.” In African Health Leaders: Making Change and Claiming the Future, edited by Francis Omaswa and Nigel Crisp. Oxford: Oxford University Press. Pp. 3–8. Painter, Thomas M.; Organista, Kurt C.; Rhodes, Scott D.; and Sanudo, Fernando M. 2012. “Interventions to Prevent HIV and Other Sexually Transmitted Diseases among Latino Migrants.” In HIV Prevention with Latinos: Theory, Research, and Practice, edited by Kurt C. Organista. Oxford: Oxford University Press. Pp. 351–381.

Migration, health, and development

169

Pires, Sonia. 2015. “Guinea-Bissau Immigrant Transnationalism in Portugal: A Substitute for a Failed State?” In Africans on the Move: Migration, Diaspora and Development Nexus, edited by Fassil Demissie. London: Routledge. Pp. 47–75. Pitkanen, Pirkko; and Kalekin-Fishman, Devorah. 2007. “Introduction.” In Multiple State Membership and Citizenship in the Era of Transnational Migration, edited by Pirkko Pitkanen and Devorah Kalekin-Fishman. Rotterdam: Sense Publishers. Pp. 1–10. Price-Smith, Andrew T. 2002. The Health of Nations: Infectious Disease, Environmental Change, and Their Effects on National Security and Development. Cambridge, MA: MIT Press. Renzaho, Andre M.N. 2016. “Health, Social and Economic Impact of Voluntary Migration.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 123–203. Rotolo, Stephanie. 2016. “Biomedicine and Traditional Healing: Is Collaboration Possible?” In Doing Development in West Africa: A Reader By and For Undergraduates, edited by Charles Piot. Durham, DC: Duke University Press. Pp. 67–82. Ruiz, Hiram A. 1994. “Training for Voluntary Repatriation: Challenges and Opportunities.” In Final Report of the International Symposium “Refugees and Development Assistance: Training for Voluntary Repatriation”, compiled and edited by Peter H. Koehn. Missoula: Office of International Programs, The University of Montana, April. Shaules, Joseph. 2007. Deep Culture: The Hidden Challenges of Global Living. Clevedon: Multilingual Matters. Sheikh, Kabir; Schneider, Helen; Agyepong, Irene A.; Lehmann, Uta; and Gilson, Lucy. 2016. “Boundary-Spanning: Reflections on the Practices and Principles of Global Health.” BMJ Global Health 1. DOI: 10.1136/bmjgh-2016-000058 Sheikh, Mubashar; and Afzal, Muhammad M. 2012. “Global Health Workforce Alliance: Negotiating for Access to Health Workers for All.” In Negotiating and Navigating Global Health: Case Studies in Global Health Diplomacy, edited by Ellen Rosskam and Ilona Kickbusch. London: World Scientific. Pp. 297–324. Smith, Richard D.; and MacKellar, Landis. 2007. “Global Public Goods and the Global Health Agenda: Problems, Priorities and Potential.” Globalization and Health 3 (9). Stevenson, Michael. 2016. “The Entrenchment of the Public-Private Partnership Paradigm.” In Case Studies on Corporations and Global Health Governance: Impacts, Influence and Accountability, edited by Nora J. Kenworthy, Ross MacKenzie, and Kelley Lee. London: Rowman & Littlefield. Pp. 119–129. Stewart, Kearsley A. 2017. “Anthropological Perspectives in Bioethics.” In International Encyclopedia of Public Health, 2nd edition, edited by Stella R. Quah. Amsterdam: Academic Press. Pp. 113–121. Sun, Ken Chih-Yan. 2014. “Transnational Healthcare Seeking: How Ageing Taiwanese Return Migrants View Homeland Public Benefits.” Global Networks 14:533–550. Suri, Arjun; Weigel, Jonathan; Messac, Luke; Basilico, Marguerite T.; Basilico, Matthew; Hanna, Bridget; Keshavjee, Salmaan; and Kleinman, Arthur. 2013. “Values and Global Health.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 245–286. Tarrow, Sidney. 2005. The New Transnational Activism. Cambridge: Cambridge University Press. Taylor, Allyn L.; and Dhillon, Ibadat S. 2012. “Transformative Diplomacy: Negotiation of the WHO Global Code of Practice on the International Recruitment of Health Personnel.” In Negotiating and Navigating Global Health: Case Studies in Global Health

170

Migration, health, and development

Diplomacy, edited by Ellen Rosskam and Ilona Kickbusch. London: World Scientific. Pp. 101–127. Terrazas, Aaron. 2010. “Connected through Service: Diaspora Volunteers and Global Development.” In Diasporas: New Partners in Global Development Policy, edited by Kathleen Newland. Washington, D.C.: Migration Policy Institute. Pp. 162–211. Topouzis, Daphne. 2004. “Moving Therapy to the Frontline of the AIDS War.” Africa Recovery (April):9–11. Uitto, Juha I.; and Shaw, Rajib. 2016. “Sustainable Development and Disaster Risk Reduction: Introduction.” In Disaster Risk Reduction: Methods, Approaches and Practices, edited by Juha I. Uitto and Rajib Shaw. Tokyo: Springer. Pp. 1–12. Ullmann, S. Heidi; Goldman, Noreen; and Massey, Douglas S. 2011. “Healthier before They Migrate, Less Healthy When They Return? The Health of Returned Migrants in Mexico.” Social Science & Medicine 73:421–428. United Nations General Assembly. 2011. “Non-Communicable Diseases Deemed Development Challenge of ‘Epidemic Proportions’ in Political Declaration Adopted During Landmark General Assembly Summit September 2011.” New York: United Nations. Vertovec, Steven. 2009. Transnationalism. London: Routledge. Vertovec, Steven; and Rogers, Alisdair. 1998. “Introduction.” In Muslim European Youth: Reproducing Ethnicity, Religion, Culture, edited by Steven Vertovec and Alisdair Rogers. Aldershot: Ashgate. Pp. 1–24. Villa-Torres, Laura; Gonzalez-Vazquez, Tonatiuh; Fleming, Paul J.; Gonzalez-Gonzalez, Edgar L.; Infante-Xibille, Cesar; Chavez, Rebecca; and Barrington, Clare. 2017. “Transnationalism and Health: A Systematic Literature Review on the Use of Transnationalism in the Study of the Health Practices and Behaviors of Migrants.” Social Science and Medicine 183:70–79. Walton-Roberts, Margaret. 2015. “International Migration of Health Professionals and the Marketization and Privatization of Health Education in India: From Push-Pull to Global Political Economy.” Social Science & Medicine 124:374–382. Weigel, Jonathan; Basilico, Matthew; and Farmer, Paul. 2013. “Taking Stock of Foreign Aid.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 287–301. Weisblat, Abraham M. 1993. “Evaluation of Overseas Fellowship Programs.” In International Investment in Human Capital: Overseas Education for Development, edited by Craufurd D. Goodwin. New York: Institute of International Education. Pp. 179–188. World Health Organization (WHO). 2010. Health of Migrants: The Way Forward. Report of a Global Consultation Held in Madrid, Spain, 3–5 March. Geneva: World Health Organization. World Health Organization (WHO). 2016. Global Strategy on Human Resources for Health: Workforce 2030. Geneva: World Health Organization. World Health Organization and World Bank. 2005. Dying for Change: Poor People’s Experience of Health and Ill-Health. Washington, DC: World Bank. Yin, Xiao-huang; and Koehn, Peter H. 2011. “Immigrant Transnationals and U.S. Foreign Relations.” In A Companion to American Immigration, 2nd edition, edited by Reed Ueda. Malden, MA: Blackwell Publishing. Pp. 77–105.

6

Pathogens without borders ERIDs as privilege leveler?

Zoonotic transmissions, public-health inequities, and biosecurity challenges underlie the transborder and transboundary dynamics involved in potential global pandemics. These conditioning factors, and the identification of emerging and reemerging infectious disease (ERID)-outbreak hotspots and urban hubs of connectivity, provide the initial grist for the transnational-transmission discussion in this South-North connectivity chapter. Lessons from the SARS and Ebola crises, including future applications of Médecins Sans Frontières’ ethics framework for medical research, improved protections for health-care workers, and rapid personnel and resource mobilization are considered along with efforts to limit the spread of infections by travelers and migrants. This chapter’s pages also explore the impacts of Northern pandemic fears and vulnerabilities, public-health services in impoverished places, and migration impulses. Aspects of global governance are especially relevant to this discussion. The World Health Assembly’s International Health Regulations (IHRs) present confinement and human rights issues of interest in this connection. The feasibility of quarantines, isolation, and social exclusion in a mobility-driven world receive attention along with limits on vaccine production and distribution and challenges of determining the allocation of ventilators, intensive-care units, and other scarce resources. The roles of enhanced clinics, surveillance, information technology, and glocal responses are considered. The increasing emphasis on community participation unmasks the changing face of glocal public health.

Transnational transmissions: ERIDs, inequities, and biosecurity The central concern of this chapter is with emerging and reemerging diseases. ERIDs can be defined as “diseases that are increasing their incidence, geographic or host species range or their impact (due, for instance, to the acquisition of resistance to antimicrobial drugs or vaccines or the acquisition of new virulence factors).”1 Thus, ERIDs include “both newly recognized pathogens and known pathogens that are ‘re-emerging’” (Horby, 2014, p. 251). Asia is “a powerhouse of social and environmental change that may facilitate the emergence of new pathogens,” and tropical regions generally contain “a rich pool of existing and

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potential pathogens that are increasingly connected, but that are also experiencing high rates of ecosystem disruption and biodiversity loss, [and] may therefore be at a particularly high risk of disease emergence” (ibid., pp. 254–255; also pp. 252–253, 259). These Southern regions of highest prevalence of highly infectious diseases correspond with the places “from which most migrants and refugees emanate” (Davies, 2010, p. 100). Increased microbial traffic involving novel zoonotic infections that cross from their natural hosts into the human population, and other already present pathogens afforded an opportunity to infect new hosts thanks to changing conditions, are a potent source of emerging pandemic diseases. Peter Daszak (2008) reports that 61 percent of emerging-infectious diseases are caused by zoonoses; three-fourths of these involve transmissions from wildlife to human populations. Animal-to-human viral infections have increased dramatically in the past decade and Daszak concludes that the future risk of emerging-infectiousdisease outbreaks will be highest in areas of substantial biodiversity that are experiencing new anthropogenic interventions. Habitat alterations, such as deforestation, “change species composition and the interaction between wild animals, domestic animals, insect vectors and humans, thereby providing new opportunities for disease emergence” (Horby, 2014, p. 256). Outbreaks of Ebola, for instance, can be traced to “deforestation in previously untouched forests, bringing humans into closer contact with rare disease strains viral enough to precipitate an epidemic” (McCoy, 2014; Kaner and Schaack, 2016). Highdensity domestic-animal husbandry has facilitated additional ERID outbreaks in Asia (Horby, 2014, p. 257). Historically, epidemics have “produced significant worry, anxiety, fear, panic, and even mass hysteria in an affected society” (Price-Smith and Huang, 2009, p. 28). Faced with high levels of uncertainty regarding the virulence and transmissibility of the pathogen, fear and panic can prompt population exodus. In short, epidemics can “generate rapid and significant migration from affected areas as people attempt to flee the source of infection” (Price-Smith, 2009, p. 20). For instance, when plague hit the city of Surat in India in 1994, “the fear of an epidemic was so intense that 500,000 residents fled in less than a week” (PriceSmith and Huang, 2009, p. 28).

Migration and biosecurity Worldwide migration and trade “are mixing people and microorganisms on an unprecedented scale” (Glasgow and Pirages, 2001, pp. 196, 203; Price-Smith, 2002, pp. 41, 165) at breakneck speed (Saker, et al., 2004, pp. 35, 37; also Brower and Chalk, 2003; Whiting, 2017). People on the move can introduce new, previously eradicated, and undetected diseases to destination places (Grondin, et al., 2003, p. 85; Garrett, 2001, pp. 185–186). Wealthy Northern countries and privileged individuals are cognizant of such volatile health threats (see Box 6.1).

10

Introduction

Fragmented governance Governance can be understood as influence over policy and action.24 Throughout the world, multiple and at times conflicting political considerations and policy decisions affect health and migration outcomes. In the current diffuse international context, a multitude of diverse and uncoordinated institutions participate in multilevel health and mobility governance (Sheikh, et al., 2016; Herrick, 2016, p. 674; Harman, 2012, pp. 6, 141; MacLean and Brown, 2009, pp. 9–10, 14). Governments at the national and subnational levels25 play important, but often not decisive, governance roles in complex-humanitarian crises. Multinational organizations, led by the World Health Organization (WHO) and the United Nations High Commission for Refugees (UNHCR), are active at the international and regional level.26 Non-state actors (see Box I.2) are other key players at different times and in different places (see, for instance, Kirton and Cooper, 2009, p. 314; MacLean and Brown, 2009, pp. 11–13; Moran, 2009; McCracken and Phillips, 2017, p. 26; Barmania and Lister, 2013; Kickbusch, et al., 2013, pp. 2–3; Davies, 2010, pp. 49–50, 55–58).

Box I.2 Some non-state actors in global health and migration governance • • • • • • • • • • • •

corporate firms (such as pharmaceutical and tobacco companies)27 Doctors Without Borders, Red Cross and Red Crescent foundations28 and philanthropic organizations29 the Global Fund to Fight AIDS, Tuberculosis, and Malaria,30 the Global Alliance for Vaccines and Immunizations (GAVI) International Rescue Committee31 indigenous humanitarian organizations (Land, 2017 , pp. 128–129) private local hospitals, faith-based entities, citizen-initiated sanctuary cities, political movements (Ottersen, et al., 2014 , p. 635) the traditional and social media academic and professional networks and expert bodies the Internet mixed-actor partnerships

Global health governance specifically refers to “trans-border agreements or initiatives between states and/or non-state actors to [sic] the control of public health and infectious disease and the protection of people from health risks or threats” (Harman, 2012, p. 2; also p. 144; also Davies, 2010, pp. 59–61). WHO is “the directing and coordinating authority for health within the United Nations system” with multiple core-leadership functions that span research and knowledgegeneration, policy articulation, norm-setting, capacity building, technical support,

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and treatment assumes increasing consequence for individual patients, receiving societies, and health-care systems (Kickbusch, 2003; Markel and Stoney, 2012). Overcrowding, poor sanitation, housing deficiencies, and widespread poverty within migrant communities produce situations conducive to the spread of communicable diseases (Davies, 2010, pp. 102–103). For instance, many migrants are segregated in places where “living conditions offer little protection from TB” (Carballo, Diivino, and Zeric, 1998, p. 937). Thus, improving living conditions for migrants lies at the forefront of health measures that will simultaneously protect individual health and reduce the risk of infections within receiving societies (Davies, 2010, p. 100).

Lessons from SARS and Ebola Both SARS and Ebola (Box 6.2) drew heightened attention to the interconnected character of global health and challenged prevailing approaches to transboundary-crisis management in fundamental ways (Olsson and Zhong, 2012, p. 243). The arising challenges involve varying implications for South and North, for localities and the international regime, and for approaches to dealing with transnational health threats. Mobility serves as the common denominator that advances pathogens without borders.

Box 6.2 2014 Scene from the Ebola isolation ward, Makeni, Sierra Leone “Where’s the corpse?” The burial worker shouted, kicking open the door of the isolation ward at the government hospital here. The body was right in front of him, a solidly built young man sprawled out on the floor all night, his right hand twisted in an awkward clentch. The other patients, normally padlocked inside, were too sick to look up as the body was hauled away. Nurses, some not wearing gloves and others in street clothes, clustered by the door as pools of the patients’ bodily fluids spread to the threshold. . . . In the next ward, a 4-year-old girl lay on the floor in urine, motionless, bleeding from her mouth, her eyes open. A corpse lay in the corner – a young woman, legs akimbo, who had died overnight. A small child stood in a cot watching as the team took the body away, stepping around a little boy lying immobile next to black buckets of vomit. They sprayed the body, and the little girl on the floor, with chlorine as they left. Source: Nossiter (2014)

Spread patterns One of the most valuable public-health interventions inspired by the SARS outbreak was the rapid virtual assembly of a global network of leading epidemiologists,

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microbiologists, virologists, and practitioners who collaborated in “identifying the causative agent responsible, recommending effective treatment options and developing tests that would assist in accurately diagnosing suspected or probable SARS cases” (Kamradt-Scott, 2015, pp. 90–91). A surprising lesson from the spread pattern of the SARS coronavirus is that certain virulent pathogens are likely to be “more transmissible in the sealed hospital and urban environments of countries with technologically sophisticated health infrastructures” than in lower-capacity, open-air health-care contexts (Price-Smith, 2009, p. 152; also Horby, 2014, pp. 258–259).2 Governance lessons At a global level, the SARS outbreak accelerated the adoption of overdue revisions to the WHO’s International Health Regulations (IHR). The revisions placed new emphasis on strengthening capacity for surveillance, alerting, and responding at the source of outbreaks; expanded the list of reportable health threats; and moved “from a pre-determined set of measures to a tailored response with more flexibility to deal with the local situation on the ground” (Crisp, 2016, p. 138). Under the 2007 revisions, member states must henceforth immediately report the following to WHO: the SARS coronavirus, novel strains of human influenza, cholera, polio, and novel diseases that could significantly harm human populations (Price-Smith, 2009, p. 153; Crisp, 2016, p. 138; Davies, 2010, p. 152). The new IHR also codify WHO’s authority to recommend that member states impose restrictions, including quarantine, at ports, airports, borders, and on means of cross-border transportation (Price-Smith, 2009, p. 154), and provide the international agency with a specific designated framework for leadership on global health emergencies (Huang, 2009, p. 133; also Kamradt-Scott, 2015, pp. 95–96).3 Global health lessons The 2014 Ebola outbreak highlighted both local and transnational lessons for glocal health. Locally, the crisis underscored the risk to health-care providers4 who come in contact with the body fluids of infected persons, the importance of immediate contact tracing and culturally trusted approaches to treatment and prevention practices, the need for additional donor and domestic funding for strengthened basic health-care facilities in the South, and the benefits of attending to the stigmatization challenges facing survivors (Kaner and Schaack, 2016; De Cock and El-Sadr, 2015, pp. 989–990; Davies, 2010, p. 155). The transnational lessons relate primarily to surveillance failures, international-population mobility, and insufficient international response measures (Kaner and Schaack, 2016). In particular, WHO’s hobbled response to the Ebola outbreak was evidenced in its decision to withdraw its [limited] international team too soon from Guinea and Liberia, poor responses to requests for technical guidance from local health

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Northern fears and border vulnerabilities In sum, “the 2014 Ebola epidemic has shown that infection-control measures can fail and that there is a significant risk from infectious disease worldwide” (Kaner and Schaack, 2016). Thanks to ERIDs, health has assumed a central place on the world’s security agenda (Davies, 2010, pp. 88, 135, 138, 141–142, 154; KamradtScott, 2015, p. 79). For instance, SARS clearly demonstrated the characteristics of infectious diseases that make outbreaks a security threat: a symptomless incubation period which allows the pathogen to spread undetected, the rapid spread made possible by air travel and the public concern heightened by access to immediate information through electronic communication methods. (Heymann and Chand, 2013, p. 131) In the past: When a journey exceeded the incubation of an infectious disease it was possible to assess the health of migrating populations at the time those individuals reached the border or frontier post. Those who were ill could be referred for appropriate treatment, if that was available, or further isolated until the risk of transmission had passed. An additional advantage . . . was that medical specialists adept at dealing with the diseases of mobile populations could be concentrated at these centers. (Gushulak, 2001, p. 257) Today, however, mobile arrivers who complete their journeys “during the clinically silent, incubation period of many infectious diseases . . . of international public health interest, can be clinically well.” Moreover, the sheer scale of border crossings, in excess of one billion annually (Osterholm and Olshaker, 2018), precludes detection. Thus, infected border crossers are likely to present with unaccustomed imported diseases “at a distance from the frontier or port of entry,” including places where medical specialists are in short supply (Gushulak, 2001, pp. 257–258). The Dallas arrival in 2014 of Thomas E. Duncan, a Liberian man carrying the Ebola virus who later infected U.S. health workers, illustrates the porousness of even stepped-up international control procedures. Screening passengers at the point of embarkation relies on fallible and premature temperature checks and thermal scans and depends on traveler honesty. In Thomas Duncan’s case, he registered a non-feverish temperature of 97.3 degrees and did not report carrying an Ebola-infected woman to and from the hospital just days previously on his departure form. U.S. customs agents who engaged in “passive surveillance”

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for overt signs of illness failed to identify Thomas as an Ebola risk (Onishi and Mouawad, 2014). Whereas refugees are subject to compulsory, albeit not always entirely effective, health screening prior to admission into Northern countries, the infectious diseases that accompany irregular migrants who arrive surreptitiously without health checks will remain undetected (Renzaho, 2016, pp. 124–128, 135; Kaiser, 2014, p. 193). Real or imagined walls5 will not screen out all infected migrants and persons infected with an ERID will continue to pass through porous border checks (Kelly, et al., 2011, pp. 213–215). The provocative future picture arising out of the world’s experience with SARS and Ebola is that ERIDs, much like committed migrants, will not always be contained in their place of outbreak and that even unequal mobility provides no safe escape from a pandemic for privileged Northerners and Southerners.

Ethical issues surrounding confinement and resource-allocation options in a mobility-driven world Given the prominent role played by human mobility in the transmission of infectious diseases, calls for isolation and quarantines typically accompany ERID outbreaks. Isolation involves keeping individuals known to have the focal disease away from others during the period that they are contagious, whereas quarantines separate persons exposed to the disease who may or may not be infected (Fidler, 2003, p. 2). Both measures potentially infringe on “civil and political rights recognized in international law, such as freedom of movement and the right to liberty” (ibid.; also see Smith, 2003, pp. B8–B9). Jerome Singh (2013, p. 66) presents a framework for public-health ethics that possesses utility for situations involving transnational migration and global health. Five containment-related principles are particularly relevant: (1) burden identification and minimization, (2) harm prevention, (3) necessity, (4) equitable implementation, and (5) transparency. Respect for autonomy and human dignity can be added to this list (Stewart, 2017, p. 6). Quarantine The limited domestic feasibility of quarantine as an epidemic-control tool became apparent in West Point, Liberia, during the Ebola outbreak (Box 6.3). That neighborhood quarantine and an earlier attempt to curtail Marburg virus in Angola collapsed in the face of public distrust and disruption of lives and livelihoods (Stewart, 2017, p. 5).

Box 6.3 Quarantine, West Point, Liberia, 2014 Soldiers and police officers in riot gear blocked the roads. Even the waterfront was cordoned off, with the coast guard stopping residents

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In the Thomas Duncan situation described earlier, moreover, the human and financial costs of using quarantine as a control procedure at points of departure became clear. In the words of Binyah Kesselly, Chair of the Liberia Airport Authority, “‘there is nothing else we could do short of quarantining people who want to travel [for] 21 days [the maximum incubation period for Ebola] before departure’” (Onishi and Mouawad, 2014). As we shall see in the case of Kaci Hickox (Box 6.5), similar human-rights challenges surrounding quarantine of symptomless travelers confront authorities at destination points. Isolation The feasibility of isolation as a containment strategy breaks down as numbers increase. No community, even in wealthy countries and global cities, possesses, or can afford the expense of acquiring, specialized facilities such as negative-pressure (isolation) hospital rooms in sufficient quantity to contain pandemic infections. In addition, voluntary and involuntary isolation (Singh, 2013, p. 64), along with the accompanying stigmatization and separation from cherished family-support networks, is problematic for care providers as well as patients (Zuger, 2010; Grady, 2005a). Containment and human rights Infection-control strategies that involve containment threaten to violate several principles set forth in the Universal Declaration of Human Rights (Singh, 2013, p. 66). In emergencies, however, public-health threats of serious consequence and scope can allow limiting certain individual rights. In these cases, the measures taken must be “legitimate, non-arbitrary, publicly rendered and necessary.” They should embody least-restrictive approaches, be of limited duration, and be subject to review (ibid., pp. 66–67). David Fidler (2003, p. 2) maintains that international or domestic public-health measures such as quarantines and isolation that infringe on human rights must (1) be prescribed by law; (2) be applied in a nondiscriminatory manner; (3) relate to a compelling interest in the form of a significant infectious

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disease risk to the public’s health; and (4) be necessary to achieve the protection of the public, meaning that the measure must be (a) based on scientific and public-health information and principles; (b) be proportional in its impact on individual rights to the infectious disease threat posed; and (c) the least restrictive measure possible to achieve protection against the infectious disease risk. Furthermore, quarantines must be feasible both economically and in the sense that exposed persons are willing to cooperate for the duration and can be placed where they can be cared for adequately and safely. These are challenging requirements: “imagine the difficulty of shooting to kill when the violator is a kindergartener trying to run home” (Smith, 2003, p. B9). The position of the World Health Organization (2010, p. 49) holds that in rare situations health threats and risks to others may justify limits to personal autonomy, privacy, and freedom. Examples include processes to mitigate the spread or extension of diseases of great international public-health importance such as highly pathogenic infections at risk of causing serious mortality or morbidity. WHO’s positon does not apply to conditions such as HIV infection. From humanrights and practical perspectives, restrictions on the entry of transnationally mobile persons living with HIV are “not a reasonable means of controlling the virus, since the virus is spread by specific behaviors rather than the mere presence of carriers” (WHO, 2010, p. 50). In any event, quarantine has fallen out of favor as a preferred response to potential pandemic situations, primarily due to multiple practical considerations. As John Hancock (2013, p. 162; also p. 168) opines, whereas in the past disease outbreak control often involved blanket quarantines or trade embargoes, health officials are now more focused on effective information sharing and early containment strategies, through early warning surveillance systems, rapid verification procedures and international response networks. And when restrictions are used, they tend to be timelimited and aimed at minimizing trade and travel disruption. Some political figures cling to mobility-restrictive measures, however. Candidate Donald Trump, for instance, viewed the evacuation of medical personnel as a threat to public health in the USA and advocated a ban on flights to the United States from Ebola-infected countries6 (see Box 6.4).7 At least 18 U.S. state governments ordered more than 40 returnees from Ebola-afflicted countries confined to their homes for up to three weeks (see Box 6.5)8 and the U.S. military imposed quarantines on 2,815 returning armed-service members (Fink, 2015a).

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Box 6.4 Donald Trump tweet after the airlift of two U.S. health workers infected with Ebola, 2014 Stop the EBOLA patients from entering the U.S. Treat them, at the highest level, over there. THE UNITED STATES HAS ENOUGH PROBLEMS! Source: Cooper (2017)

Quarantines, bans on evacuation, and isolation upon return to the home country all serve as strong disincentives for future involvement on the part of transnational health-care volunteers. Paradoxically, according to then CDC Director Thomas R. Frieden, dissuading medical volunteers from responding to ERID outbreaks would allow the infection to spread and, thereby, increase the risk of exposure by persons residing in the North (Fink, 2015a).

Box 6.5 The quarantine of Kaci Hickox upon return from five weeks treating Ebola patients in Sierra Leone I feel like I could run a marathon but my heart is aching. . . . They tested me for Ebola last night even though I did not meet any criteria that would merit such a test. Although I tested negative for Ebola, there is no sign I will be able to leave this plastic prison-tent. . . . I am healthy with no symptoms of Ebola, yet I have been told no one can come and see me through the plastic window of the tent. I know I cannot give anyone Ebola because I do not have symptoms. My rights have been taken away as if they do not matter and the wrong people are making decisions, people without expertise in public health or medicine. Source: Hickox (2015, p. 9)

Vaccine manufacture While quarantine by necessity involves limited recourse, the availability or nonavailability of vaccines presents mass ramifications. First, the existing system of vaccine manufacturing is fragile and plodding; “it requires waiting four to six months after the onset of a pandemic, but an outbreak would have to be contained within three weeks” (Huang, 2009, p. 132).9 Further, most of the world’s vaccine-production capacity is located in a handful of Northern (mainly European) countries, placing populations in the South, where poverty and weak health systems heighten vulnerability to ERID outbreaks (McCracken and Phillips,

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2017, p. 194), at a decided disadvantage in terms of equitable distribution of this scarce resource (Huang, 2009, p. 133). Faced with what Michael Osterholm and Mark Olshaker (2018) deem to be the “coming influenza pandemic,” even Northern residents would “never even have a chance to be vaccinated” given current limited manufacturing capacity, the time required to produce a vaccine, and lack of population proximity.10 Scarce life-saving resources Additional challenging ethical issues in both Northern and Southern contexts involve the allocation of scarce life-saving resources in the midst of an epidemic. During the West African Ebola epidemic, “when doctors and nurses could spend only so many minutes inside hot biohazard suits, they struggled with impossible choices over which patients to give care” (Fink, 2016). Also at stake here are costly and limited machines and facilities such as ventilators and negative-pressure rooms. Who should receive priority access when there is vastly insufficient supply? One approach calls upon random selection or first-come-first-served rationing of life-and-death care. Another decision principle advanced focuses on the likely number of remaining years of productive life (Fink, 2016). Some would argue that saving health personnel and other critical professionals should receive priority. Should irregular migrants be denied access? Charles Blattberg, Professor of Political Philosophy at the University of Montreal, maintains that “the kind of judgment that’s required to arrive at a good decision in these situations needs to be extremely sensitive to the context” (cited in Fink, 2016). The conclusion we can reach at this time is that the ethical dilemmas surrounding allocation of scarce life-saving resources in the midst of an epidemic lack consensus, tend to be avoided, and remain unresolved nearly everywhere. Given the rise in migrant-health situations that generate pressures for quarantines, isolation, and triage, moreover, “people preparing for careers in public health need to learn that their discipline is as much about politics as medicine, a fact of life that is never clearer than in the imperfect compromises that are often required” (Smith, 2003, p. B9; also see Lencucha and Mohindra, 2014, p. 66). Securitization Securitization of health issues is faulted by some on grounds that is has created “a hierarchy of disease ‘threats,’” with those that carry the potential to threaten wealthy countries commanding the greatest attention and resources, while those that only affect people in Southern countries receive “considerably less” (Kamradt-Scott, 2015, p. 158). At another level, the heavy involvement of security-sector forces (military, police, intelligence) brought about by the increased tendency to treat pandemics as security threats potentially reduces the salience of “health/humanitarian principles and/or human rights” (ibid., p. 153). Underlying unease over “securitization” is concern that increasing entanglement

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by security forces will undermine “the authority of medical/health professionals (as self-appointed guardians of . . . humanitarian principles and rights) and their ability to directly shape the response to a health problem” (ibid., p. 153). The prevailing ERID situation calls for creative approaches to NGO-security force cooperation (ibid., p. 189) that enable the building of local capacity to prevent and respond to outbreaks, respect health expertise, and maintain ethical approaches to crisis management.

Glocal responses to ERIDs that incorporate community participation at the core Employing advanced-digital-surveillance technologies that draw heavily on non-state information sources (Huang, 2009, p. 133; Davies, 2010, p. 151), groups like Global Viral Forecasting (GVF) and HealthMap are linking “viral chatter” to epidemiology in an effort to stay one step ahead of brewing pathogen outbreaks. Bio.Diaspora, a University of Toronto project, “integrates real-time information on infectious diseases with data on global travel patterns” (Walsh, 2011). These promising initiatives depend in the first instance on reliable data collected at equipped health outposts and rapidly forwarded from remote and isolated areas by trained and astute health workers (Horby, 2014, p. 261). Nevertheless, “with a novel, swiftly spreading deadly infection, enormous numbers of deaths could occur before any effective medical treatment could be produced even with the current better surveillance programmes” (McCracken and Phillips, 2017, p. 377). At the same time as they stoke fear and panic, epidemics “often coexist with passion for the sick and poor” and generate increased social cohesion and robust civil-society collective action (Huang, 2009, pp. 141, 143; also see Shen, 2012, p. 87). Promising community-based interventions include source control through early case identification, rapid contact tracing, and monitoring of high-risk individuals (Kaner and Schaack, 2014); expanding social distance by closing schools and canceling mass gatherings (Shen, 2012, p. 87; Kelly, et al., 2011, pp. 215– 216); and personal infection-control practices such as hand washing, wearing effective masks, and modeling alternatives to handshake greetings (Horby, 2014, p. 262). In addition, instead of stigmatizing migrants, public-health professionals in today’s interconnected world must be skilled at engaging in cooperative-health care across borders with state and non-state counterparts. Vital transnational-collaborative undertakings include laboratory work, epidemiological investigation, diagnosis, reporting, exposure management, and specimen handling (Gerberding, 2003). Prevention and rapid (pre-migration) treatment at its source rank among the most effective global responses to an ERID. For this reason, strengthening health systems in poor countries, preventing environmental degradation, and engaging community participation through effective coalitions of proximate and outside responders constitute core components going forward (Price-Smith and Huang, 2009, p. 43; De Cock and El-Sadr, 2015, p. 989). To succeed, the overall approach must be glocal in nature and address entrenched inequities in health care.

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Given the practical and human-rights challenges involved in attempting to limit the spread of communicable diseases through border controls, many experts have concluded that improving health systems in the South, including increased local availability of trained and transnationally competent public-health workers, offers the most promising strategy for mitigating ERID outbreaks (Zacher, 1999, p. 275; Grady, 2005b). Funding that will address poverty by promoting sustainable development and will support health-system strengthening in the South (Chapter 5) must be part of the overall equation. World Bank President Jim Yong Kim’s proposal to establish an emergency fund to address ERIDs (McNeil, 2017) would provide another valuable component in a proactive forward-looking transnational strategy in humanity’s interests.

Notes 1 The spread of a new drug-resistant strain of malaria in Vietnam and Cambodia in 2017 closely fits this definition (Ives and McNeil, 2017). 2 The 2014 outbreak of Ebola was amplified exponentially once the disease reached West African urban centers (Kaner and Schaack, 2016). 3 Nevertheless, restoring WHO’s budget to an extent that will allow the international organization to operate effectively at times of crisis remains to be undertaken (Kamradt-Scott, 2015, p. 176; Fink and Belluck, 2015). Other administrative reforms dealing with WHO’s emergency-response capacity and protection from political interference at headquarters, regional-office, and national levels are underway and under consideration (Fink, 2015b). 4 Health-care providers in Hong Kong also suffered disproportionately during the initial stages of the SARS outbreak (Shen, 2012, p. 76). 5 “I would build a great wall, and nobody builds walls better than me, believe me, and I’ll build them very inexpensively, I will build a great, great wall on our southern border. And I will have Mexico pay for that wall.” “Full Text: Donald Trump Announces a Presidential Bid.” Washington Post, 16 June 2015. 6 Along with the suspension of visa issuing for citizens of those places (Lee, 2017). 7 A total of 46 infected or exposed health care workers arrived at special treatment centers in the United States during the 2014 Ebola outbreak. In April 2017, however, the Trump administration engaged in drills designed to prepare for even larger-scale future evacuations (Lee, 2017). 8 None of those quarantined developed Ebola, although many reported lost wages, stress, and fear (Fink, 2015a). 9 Led by Bill Gates, voices raised in the aftermath of the Ebola experience are advocating creation of a system for accelerated approval of drugs and vaccines in crisis situations involving diseases likely to result in epidemics (Kaner and Schaack, 2016). 10 Osterholm and Olshaker (2018) contend that the only solution is research commitment to developing “a universal vaccine that effectively attacks all influenza A strains with reliable protection lasting for years, like other modern vaccines.”

References Brower Jennifer; and Chalk, Peter. 2003. The Global Threat of New and Reemerging Infectious Diseases: Reconciling U.S. National Security and Public Health Policy. Santa Monica: Rand Corporation. Carballo, Manuel; Diivino, Jose J.; and Zeric, Damir. 1998. “Migration and Health in the European Union.” Tropical Medicine and International Health 3, No. 2 (December):936–944.

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Cooper, Helene. 2017. “Memo’s Tone May Signal Retreat from Africa Aid.” New York Times, 14 January, p. A11. Crisp, Nigel. 2016. One World Health: An Overview of Global Health. Boca Raton, FL: CRC Press. Daszak, Peter. 2008. “Why Do Emerging Diseases Happen & What Can We Do to Stop Them?” Lecture presented at The University of Montana, 10 November. Davies, Sara. 2010. Global Politics of Health. Cambridge, UK: Polity Press. De Cock, Kevin M.; and El-Sadr, Waffa M. 2015. “A Tale of Two Viruses: HIV, Ebola and Health Systems.” AIDS 29:989–991. Fidler, David P. 2003. “SARS and International Law.” American Society of International Law Insights (April):1–3. Fink, Sheri. 2015a. “Debate on Quarantine Persists as Ebola Outbreak Subsides.” New York Times, 3 December, p. A1. Fink, Sheri. 2015b. “Panels Advise Bolstering W.H.O. for Crises Like Ebola.” New York Times, 22 November. Fink, Sheri. 2016. “Whose Lives Should Be Saved? Researchers Ask the Public.” New York Times, 21 August. Fink, Sheri; and Belluck, Pam. 2015. “One Year Later, Ebola Outbreak Offers Lessons for Next Epidemic.” New York Times, 22 March. Garrett, Laurie. 2001. “The Return of Infectious Disease.” In Plagues and Politics: Infectious Disease and International Policy, edited by Andrew T. Price-Smith. London: Palgrave Macmillan. Pp. 183–194. Gerberding, Julie L. 2003. “SARS: Assessment, Outlook, and Lessons Learned.” Prepared witness testimony before the House Committee on Energy and Commerce, 7 May. www. energycommerce.house.gov/108/Hearings/05072003hearing917/Gerberding Glasgow Sara M.; and Pirages, Dennis. 2001. “Microsecurity.” In Plagues and Politics: Infectious Disease and International Policy, edited by Andrew Price-Smith. London: Palgrave. Pp. 195–213. Grady, Denise. 2005a. “Deadly Virus Alters Angola’s Traditions.” New York Times, 19 April, p. A3. Grady, Denise. 2005b. “Training Is First Task in Angola Outbreak.” New York Times, 1 April, p. A9. Grondin, Danielle; Weekers, Jacqueline; Haour-Knipe, Mary; Elton, Akram; and Stukey, Julia. 2003. “Health – An Essential Aspect of Migration Management.” In World Migration 2003: Managing Migration Challenges and Responses for People on the Move, edited by Thomas L. Weiss. Geneva: International Organization for Migration. Pp. 85–93. Gushulak, Brian. 2001. “Health Determinants in Migrants: The Impact of Population Mobility on Health.” In Health, Migration and Return: A Handbook for a Multidisciplinary Approach, edited by Peter J. van Krieken. The Hague: T.M.C. Asser Press. Pp. 255–268. Hancock, John. 2013. “Global Trade and Health Diplomacy: Maximizing Cooperation and Minimizing Conflict through Coherent International Rules.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 155–171. Heymann, David L.; and Chand, Sudeep. 2013. “Diplomacy and Global Health Security.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 125–139. Hickox, Kaci. 2015. “Caught between Civil Liberties and Public Safety Fears: Personal Reflections from a Healthcare Provider Treating Ebola.” Journal of Health & Biomedical Law 11 (1):9–23.

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Horby, Peter. 2014. “Emerging Infectious Diseases in Asia.” In Routledge Handbook of Global Public Health in Asia, edited by Sian M. Griffiths, Jin Ling Tang, and Eng Kiong Yeoh. London: Routledge. Pp. 251–264. Huang, Yanzhong. 2009. “In-Flew-Enza: Pandemic Influenza and Its Security Implications.” In Innovation in Global Health Governance: Critical Cases, edited by Andrew F. Cooper and John J. Kirton. Burlington, VT: Ashgate. Pp. 129–152. Huang, Yanzhong. 2016. “How to Reform the Ailing World Health Organization.” Council on Foreign Relations Expert Brief, 3 May. www.cfr.org/expert-brief/how-rerformailing-world-health-organization; accessed 24 April 2018. Ives, Mike; and McNeil, Donald G. 2017. “As Drug-Resistant Malaria Spreads, Experts Warn of a Global Crisis.” New York Times, 23 November, p. A12. Kaiser, Tania. 2014. “Crisis? Which Crisis? Families and Forced Migration.” In Crisis and Migration: Critical Perspectives, edited by Anna Lindley. London: Routledge. Pp. 181–202. Kamradt-Scott, Adam. 2015. Managing Global Health Security: The World Health Organization and Disease Outbreak Control. New York: Palgrave Macmillan. Kaner, Jolie; and Schaack, Sarah. 2016. “Understanding Ebola: The 2014 Epidemic.” Globalization and Health 12:53. Kelly, Heath A. 2011. “We Should Not Be Complacent about Our Population-Based Public Health Response to the First Influenza Pandemic of the 21st Century.” BMC Public Health 11 (78):212–219. Kickbusch, Ilona S. 2003. “SARS: Wake-Up Call for a Strong Global Health Policy.” Yale Global Online. yaleglobal.yale.edu/display.article?id=1476 Lee, Matthew. 2017. “Feds Practice Ebola Evacuations Despite Past Trump Criticism.” www.apnews.com/19e03ab908584ed2995efcb2c255f4e6; accessed 2 December 2017. Lencucha, Raphael; and Mohindra, Katia. 2014. “A Snapshot of Global Health Education in North American Universities.” Global Health Promotion 21 (1):63–67. Markel, Dan; and Stoney, Christopher. 2012. “Lessons Learned from the Greater Toronto Outbreak.” In SARS from East to West, edited by Eva-Karin Olsson and Lan Xue. Lanham, MD: Lexington Books. Pp. 141–168. McCoy, Terrence. 2014. “How Deforestation Shares the Blame for the Ebola Epidemic.” Washington Post, 8 July. McCracken, Kevin; and Phillips, David R. 2017. Global Health: An Introduction to Current and Future Trends. London: Routledge. McNeil, Donald G., Jr. 2017. “Ready for a Pandemic? Only Six Nations Know.” New York Times, 1 August, p. D4. Nossiter, Adam. 2014. “A Hospital from Hell, in a City Swamped by Ebola.” New York Times, 1 October. Olsson, Eva-Karin; and Zhong, Kaibin. 2012. “Transboundary Crisis Management: Implications for Research and Practice.” In SARS from East to West, edited by Eva-Karin Olsson and Lan Xue. Boulder, CO: Lexington Books. Pp. 226–248. Onishi, Norimitsu. 2014. “Clashes Erupt as Liberia Sets a Quarantine.” New York Times, 21 August, p. A1. Onishi, Norimitsu; and Mouawad, Jad. 2014. “Journey Illustrates How Global Travel Is Open to the Spread of Disease.” New York Times, 3 October, p. A15. Osterholm, Michael T.; and Olshaker, Mark. 2018. “A Flu Pandemic Is Coming.” New York Times, 9 January, p. A23. Price-Smith, Andrew T. 2002. The Health of Nations: Infectious Disease, Environmental Change, and Their Effects on National Security and Development. Cambridge, MA: MIT Press.

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Price-Smith, Andrew T. 2009. Contagion and Chaos: Disease, Ecology, and National Security in the Era of Globalization. Cambridge, MA: MIT Press. Price-Smith, Andrew T.; and Huang, Yanzhong. 2009. “Epidemic of Fear: SARS and the Political Economy of Contagion.” In Innovation in Global Health Governance: Critical Cases, edited by Andrew F. Cooper and John J. Kirton. Burlington, VT: Ashgate. Pp. 23–48. Renzaho, Andre M.N. 2016. “Health, Social and Economic Impact of Voluntary Migration.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 123–203. Saker, Lance; Lee, Kelley; Cannito, Barbara; Gilmore, Anna; and Campbell-Lendrum, Diarmid. 2004. Globalization and Infectious Diseases: A Review of the Linkages. Geneva: World Health Organization. Shen, Simon. 2012. “The SARS Crisis and Crisis Management in Hong Kong.” In SARS from East to West, edited by Eva-Karin Olsson and Lan Xue. Lanham, MD: Lexington Books. Pp. 70–106. Singh, Jerome A. 2013. “Global Health Governance and Ethics.” In An Introduction to Global Health Ethics, edited by Andrew D. Pinto and Ross E.G. Upshur. London: Routledge. Pp. 58–72. Smith, Jane S. 2003. “The Personal Predicament of Public Health.” Chronicle of Higher Education, 27 June, pp. B7–B9. Stewart, Kearsley A. 2017. “Anthropological Perspectives in Bioethics.” In International Encyclopedia of Public Health, 2nd edition, edited by Stella R. Quah. Amsterdam: Academic Press. Pp. 113–121. Tatem, Andrew J.; and Smith, David L. 2010. “International Population Movements and Regional Plasmodium Falciparum Malaria Elimination Strategies.” Proceedings of the National Academy of Sciences 107 (27):12222–12227. Walsh, Bryan. 2011. “Virus Hunter.” Time, 7 November, pp. 36–39. Whiting, Ed. 2017. “‘Antibiotic Apocalypse’: Doctors Sound Alarm over Drug Resistance.” Observer, 8 October. World Health Organization (WHO). 2010. Health of Migrants: The Way Forward. Report of a Global Consultation Held in Madrid, Spain, 3–5 March. Geneva: World Health Organization. Zacher, Mark W. 1999. “Global Epidemiological Surveillance: International Cooperation to Monitor Infectious Diseases.” In Global Public Goods: International Cooperation in the 21st Century, edited by Inge Kaul, Isabelle Grunberg, and Marc A. Stern. Oxford: Oxford University Press. Pp. 266–283. Zuger, Abigail. 2010. “Isolation, an Ancient and Lonely Practice, Endures.” New York Times, 31 August, p. D5.

7

Climate change, health, and migration The wild card in the deck

The connection of greenhouse-gas (GHG) emissions to population health and migration in the face of waning mitigation opportunities features in this chapter. Here we explore how extreme climatic events and slow-onset changes in climate and environmental conditions and attendant ecological, economic, and social disruptions are related to population mobility and unequal global health outcomes. The early warning case of China is examined in-depth. Are population health concerns driving China to assume a vanguard position in mitigating carbon emissions? The climate/health nexus is receiving growing recognition in international circles. In 2009, the Global Health Commission of Lancet and University College London issued a call for “a public health movement that frames the threat of climate change for humankind as a health issue” (Costello, et al., 2009, p. 1696). The Intergovernmental Panel on Climate Change’s (IPCC) 2014 report assesses the likelihood of multiple negative impacts on health associated with projected climate change (see Crisp, 2016, p. 110). Citing the co-benefits that accrue from addressing anthropogenic drivers of climate change, the 2015 Lancet Commission on Health and Climate Change concluded that “Climate change could be the greatest public health opportunity of the 21st Century” and set forth a set of specific policy recommendations for tackling the linkage of GHG emissions to climate change and health (Watts, 2015). Migration complicates the picture. Looking toward the future, Chapter 7 considers prospects that massive resettlement of ecological migrants will be required in the absence of powerful emission-mitigation responses. How will the world care for climate migrants? Will countries that bear special responsibility for exacerbating climate change recognize the interconnected political, economic, and environmental drivers of migration and transform their entry systems accordingly? What are the global health implications if wealthy countries decide to forestall the arrival of climate migrants? Will diasporas become influential actors in climate-change mitigation and adaptation? These are some of the critical questions addressed in this chapter.

GHG emissions and population health: lessons from China Domestic health and migration imperatives have pushed emission-mitigation measures to the forefront of self-interest concern over climate change among

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China’s national and subnational policy makers (see Koehn, 2016). Two terrifying consequences, air pollution and sea-level rise, largely account for China’s ascendancy to the forefront of climate-change policy and action. A third impact, water stress (including drought) and spreading desertification, has contributed to “the world’s largest environmental migration project.” The Government of China has resettled more than one million environmental migrants in Ningxia Hui Autonomous Region along the ancient Silk Road in the wake of climate change and other land and water stressors (Wong, 2016b, p. A1).1 Air pollution The number of premature deaths due to chronic ambient pollution is truly frightinducing for China. Annual mortality estimates range from 400,000 to 1,200,000 inhabitants (Jahn, et al., 2013, p. 403; Wong, 2013a; United Nations Environment Programme (UNEP), 2013, p. 9). A joint UNDP-WHO study found air pollution responsible for an estimated 500,000 unnecessary deaths per year in 28 Mainland urban centers (Porter, Shi, and Zhao, 2003, pp. 40, 22n). Subsequently, the Global Burden of Disease report more than doubled the UNDPWHO calculation; this study estimated that outdoor air pollution contributed to 1.2 million premature deaths in China in 2010 (Wong, 2013a, 2013b). All 74 cities in China studied by the Government in 2013 exceeded WHO’s airborne-particulate standards for PM2.5 (which lodges deep in the lungs and enters the bloodstream) and PM10 – a coarser particulate matter (Makinen, 2014; Wong, 2014; Lu and Gill, 2007, p. 4). Urban sources for particulate matter (PM) include motor vehicles, industrial emissions, and power generation (Wong and Wong, 2014, p. 312). Burning coal is the deadliest source of air pollution in China’s cities (Wong, 2016a). However, ground level vehicle emissions have replaced coal soot as the principal generator of air pollution in urban China (Qian, Finamore, and Clegg, 2003, p. 35; Qi, 2013, p. 318). Vehicle emissions are associated with “brain damage, respiratory problems and infections, lung cancer, [and] emphysema” among other leading causes of mortality (Paterson, 2000, p. 259; also Lu and Gill, 2007, p. 4). PM2.5 concentrations at 40 times the level deemed safe by the World Health Organization have been reported in the cities of Harbin (ten million residents) (Wong, 2013b) and Shijiazhuang (Buckley and Wu, 2017). During the first three months of 2015, 90 percent of 360 monitored Chinese cities failed to meet the Government’s PM2.5 standards (Wong, 2015b). Beijing sent out its highest level of smog alert on 16 December 2016 and, during the first five weeks of 2017, the PM2.5 concentration in Beijing was nearly two times higher than in 2016. The amount of fine particulates in the air constitutes the most dangerous factor in terms of health impact. Fine particles (PM2.5) penetrate deeply into the respiratory system (SEI, 2002, p. 27). Short-term and long-term exposure to PM2.5 is linked to various illnesses and to premature death from lung and cardiovascular disease (Andrews, 2008/2009, pp. 7, 9; Wong and Wong, 2014, p. 312; Samet and Zhang, 2014, p. 289).

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Threats to personal and family health and livelihood attributable to local pollution feature prominently in the risk perceptions of China’s population (Martens, 2007, p. 72). In the words of Peggy Liu, founder of the Joint U.S.-China Collaboration on Clean Energy, Chinese parents “‘shouldn’t have to check our air quality index app on our phone every day to determine whether we should let our children outside to play’” (cited in Friedman, 2013). The powerfully illustrated and compelling video Under the Dome produced by former China Central Television (CCTV) reporter Chai Jing, and viewed by at least 200 million netizens across China in 2015, demonstrated the power of health appeals among China’s citizens. Interspersed with decades-endured scenes of air pollution, compelling statistics about the scarcity of clean-air days, and interviews with domestic scientists and doctors, the 104-minute-long documentary focuses on vividly depicting the detrimental health effects, especially for children and the elderly, of air pollution in China.2 Within days, “the film generated a huge, emotional response online, including angry comments directed at China’s political authorities” (Tharoor, 2015). People’s perceived issue salience (see Huang and Yang, 2017, pp. 4, 7, 9) regarding readily discernable immediate and long-term health threats attributable to air pollution (the urban “airpocalypse”) has advanced China’s policy tipping point. Domestically, Premier Li Keqiang, who promised on state television in 2014 that China would “‘declare war on pollution’” (Wong, 2015a), vowed in the wake of the irate public reaction to the documentary Under the Dome, to “‘make businesses that illicitly emit and dump pay a price too heavy to bear’” by using “‘not a stick of cotton candy but a powerful mace’” (cited in Wong and Buckley, 2015). Prodded by the popular reaction to Under the Dome, all levels of government in China are taking notice of the rising volume of public dissatisfaction and criticism galvanized by debilitating air.3 The response has been astonishing. Within four years of Premier Li Keqiang’s declaration, China’s mandated pollution-reduction actions have “laid the foundation for extraordinary gains in life expectancy” (Greenstone, 2018). Michael Greenstone (2018) calculates that, nationally, China’s residents can expect “to live 2.4 years longer on average”, and residents of Beijing “3.3 years longer” if the recorded declines in fineparticulate air pollution persist. Given the tight connection of air pollution and CO2 emissions, a war on pollution simultaneously amounts to a war on carbon emissions and a struggle for health promotion. Air pollution and GHG emissions arise largely from the same sources and combustion processes (Gomez-Echeverri, et al., 2010, p. 69; Bell and Samet, 2005, p. 357; Chiu, et al., 2007, p. 117; Bryner and Duffy, 2012, pp. 2, 28). Policies and technologies that diminish ambient air pollution in China, therefore, simultaneously reduce GHG emissions and population morbidity and mortality (Bell and Samet, 2005, p. 357; Chiu, et al., 2007, p. 121). The synergistic relationship between diminished air pollution and positive health promotion is underscored by studies showing that “each percent of CO2 emissions reduction will typically reduce health impacts from fine particulate air pollution by one percent” (Gomez-Echeverri, et al., 2010, pp. 69, 71, 93–94, 102).

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From laggard to leader Internationally, China’s own population health interests catalyzed a leap into the climate-change driver’s seat. At the January 2017 World Economic Summit in Davos, Switzerland, President Xi Jinping referred to the Paris Agreement as “‘a responsibility we must shoulder for the sake of our future generations’” (cited in Wong, 2017). When President Donald Trump later announced that the United States would withdraw from the Paris Agreement, China indicated readiness and willingness to rise to a leadership role in climate-change mitigation and solution generation and affirmed its commitment to the Paris accord. How can we explain China’s remarkable and swift transition from climate laggard to climate leader? Part of the explanation certainly relates to the void created by U.S. withdrawal and China’s increasingly assertive role on the global stage. Since the SARS outbreak, for instance, China has “become more proactive in participating in global health governance” (Chan, Chen, and Xu, 2012, pp. 211–213). Fundamentally, however, China’s leap to the vanguard in climatechange diplomacy rests on the ascendancy of domestic imperatives over externalattribution considerations. Attribution arguments regarding climate change4 are increasingly overshadowed by interest-based considerations as the consequences of inaction mount and spread. The concomitant curse and blessing of climate change is that no one escapes it. China’s political leadership grew to recognize that the country has much to lose from the domestic consequences of failure by the world’s largest emitter, along with others, to curb CO2 emissions. In short, domestic health and migration imperatives initially pushed emission-mitigation measures to the forefront of self-interest concern over climate change among China’s national and subnational policy makers. The policy shift to a more forceful role at the global level received additional impetus from recent research showing that episodes of severe smog in China can be traced, in part, to “unusually stagnant air condition brought on by climate change” (Hernandez, 2017). Diminished urban ventilation in China, researchers found, is connected to changing wind patterns associated with GHG-emissions-induced ice melting in the Artic combined with increased snowfall in Siberia (ibid.). This finding reinforces leadership conviction that the devastating health consequences of air pollution in China require global as well as local solutions.

Sea-level rise Sea-level rise, the second terrifying consequence propelling China’s remarkable diplomatic transition regarding anthropogenic climate change, is tied to displacement and migration and portends potentially massive future economic and human disruption. Globally, “about 145 million people live [today] three feet or less above current sea level” (Goodell, 2017, p. 14). Rising sea levels in China and other Northern-latitude coastal countries are linked to fossil-fuel burning and prospects for collapse of Antarctica’s ice sheets in the face of continued

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global warming (Goodell, 2017, pp. 55, 11–12). One recent study of changes in the West and East Antarctica ice sheets warns that “the sea level could rise as much as six feet by the end of this century,” with catastrophic consequences for sea-proximate dwellings, property, and buildings (cited in Gillis, 2017a, p. A12; also see Pierre-Louis, 2018). For people inhabiting coastal areas, the rate at which seas rise will matter more than the height (Goodell, 2017, pp. 10–14). In a worstcase scenario, “a rapid deterioration of Antarctica might . . . cause the sea to rise so fast that tens of millions of coastal refugees would have to flee inland, potentially straining societies to the breaking point” (Gillis, 2017a, p. A11; also see Goodell, 2017, pp. 52–55, 69, 182). Rising sea levels and saltwater intrusion present particularly serious intergenerational problems for China’s sinking coastal megacities (Li, 2013, pp. 114–115; Vandenbergh, 2008, pp. 919–920; Kai, 2007; Liu, 2009, pp. 91–92). In the near future, China’s densely populated coastal areas, where most productive industrial and commercial cities are located, are threatened by flooding from storm surges associated with increased typhoon activity and by the contamination of freshwater supplies due to saltwater intrusion (Cao, Gemmer, and Jiang, 2012, pp. 61–62, 65; Han, Hou, and Wu, 1995, pp. 82, 88–93). The interconnected and costly threats posed by sea-level rise include inundation, property and infrastructure destruction, population dislocation, obstructed drainage, vector spread, waterborne diseases, decreased availability of freshwater, and disrupted transportation (Young, 2013, p. 78; UNHSP, 2011, p. 66; Hu, 1995, p. 334). Guangzhou, Shanghai, and Tianjin rank among the world’s most exposed megacities in terms of infrastructure assets (UNHSP, p. 71). Shanghai is particularly vulnerable to the layering of coastal hazards, including land subsidence (Blackburn and Marques, 2013, pp. 4, 12–13). As a result of subsidence, “the ground level in the city centre is now more than half a meter below sea level” (Cumming and Layne, 2013, p. 232). In these three densely populated and economically dynamic centers alone, a sizeable proportion of China’s annual GDP and up to 130 million people are at risk (Adger, et al., 2001, p. 577). According to former U.S. Energy Secretary Stephen Chu, sea-level rise would displace greater numbers of people in China than in any other country, including Bangladesh (cited in Bradsher, 2009, p. A10). Unplanned migration of such magnitude “has significant public-health implications at its origins, along the migration routes and in the receptor areas” (Samet and Zhang, 2014, p. 292). Flood prevention in the face of sea-level rise is prohibitively expensive (Tanner and Horn-Phathanothai, 2014, p. 77) and evacuation of urban populations and industries and their relocation in newly built communities is mind-boggling in terms of logistics, costs, and increased stress and public-health threats. Mass migration, resettlement, and reconstruction also would be extremely GHGemissions exacerbating. In sum, the prospective forced-relocation challenges associated with substantial sea-level rise brought about by anthropogenic climate change present China with terrifying human and economic threats to national self-interest that compel the urgent pursuit of proactive mitigation over adaptation responses.

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Going forward: the power of health framing Domestic health and migration considerations can generate global policy transformation. The daunting linkage of climate health, public health, and migrant health has driven China’s leadership to rise to address the global GHG-emissionmitigation leadership void.5 However, China remains the world’s largest carbon emitter, roughly double the U.S. figure (Gillis, 2017b) and “more than the United States and the European Union combined” (Porter, 2014, p. B4). To truly lead, the next step for China is to “walk the talk.” In particular, if China is to make substantial progress in future emissions reductions, escalating householdconsumption trends and motor-vehicle usage must be addressed (Koehn, 2016, pp. 125, 167–169; Shapiro, 2012, pp. 34, 37–38, 171, 181; Guo, 2015).6 In China, as elsewhere, preventive appeals based on direct climatic impact are less likely to be transformative than are climate-incidental framings that focus on anticipated costs and co-benefits. The key to widespread emission-mitigating behaviors is issue bundling, or frame extension, in ways that link climatic stabilization to cherished place-based values and resonate in compelling ways with local grievances, worries, and desires (see Koehn, 2010). Public concern over the immediate and next-generation health consequences of air pollution is a particularly compelling frame-extension appeal in China, India, and Pakistan.7 China’s subnational authorities, who shoulder primary responsibility for funding health care and health facilities (Uretsky, 2016, p. 193) and addressing GHG emissions (Koehn, 2016), stand to reduce costs and make a difference by supporting preventative actions. Based on cultural and pragmatic considerations, urban populations in China are especially receptive to wellness (including stress-reduction) appeals (see Koehn, 2016, p. 121). In addition to the health benefits associated with reduced air pollution so powerfully documented in Under the Dome, low-carbon living can be individually attractive because it provides protection against diseases of affluence – “obesity, diabetes, and heart disease especially” (Costello, et al., 2009, p. 1696). A well-designed co-benefits framing strategy that links air pollution and GHG-emission reduction and continued renewable-energy development with individual and community concerns for morbidity and mortality reduction and healthy human development for all can resonate powerfully both domestically and with Chinese transnationals (Koehn, 2016, pp. 168, 170–174; Suri, et al., 2013, p. 284). Effectively implemented, this approach will enable China to become the behavioral model that embodies its newly claimed vanguard position in the international climate change regime. Furthermore, the creeping negative implications of uncontrolled urban air pollution for sustainable development and human-capability investment in China are linked to elite migration. Urban residents who survive dangerous PM2.5 levels function in an environment that has reached “the limit of endurance” (Han Wenke, cited in Buckley, 2014). In a revealing February 2014 message, the Shanghai Academy of Social Sciences declared Beijing “‘almost unfavorable for human living’” (cited in Wong, 2014). Fed up with the health threats associated with urban

12

Introduction

differentiated circumstances. Thus, place and health interact in a dynamic and uncertain manner with emergent and unintended consequences (Herrick, 2016, pp. 677–678, 683). In a helpful insight regarding global governance, Kearsley Stewart (2017, p.  115) reminds us that the ultimate relevance of public-health-care recommendations and regulations generated “beyond the borders of nation states” is dependent on acceptance “at the local level where they become lived experiences.” Since global governance is no longer exclusively determined by inter-state negotiations, “transnational relations are not squeezed into diplomatic rules and traditional means of exerting pressure on other states by the application of power politics or through the complicated mechanisms of international organizations” (Hein, 2013, p. 64). In global health and migration matters, like other forms of governance, therefore, one must not overlook “the ability of people and places to resist, evade, and exceed governance efforts” (Herrick, 2016, p. 683). Free and secure, WhatsApp “has become the lingua franca among people who, whether by choice or force, have left their homes for the unknown” (Manjoo, 2016, p. B1). Nevertheless, “when health is compromised by transnational forces,” the response must include global actors, norms, and improved responses (Ottersen, et al., 2014, p. 637; also pp. 630, 632). Amid the diversity, complexity, and contingency of a multilayered governance process, the quest for equity across a variety of challenges provides the “driving force of the global health agenda” (Kickbusch and Rosskam, 2012, p. 4; also pp. 2–3) and the basis for agreement that health is a human right for all people (WHO, 2010, p. 47). Kabir Sheikh and colleagues (2016) maintain that global health practices must “actively span and disrupt boundaries . . . which are rooted in imbalances of power and resources.” In these efforts, transnational learning networks, local communities of practice, and “learning organisations with a global outlook in low and middle-income countries can be effective boundary-spanners, and need to be supported” (Sheikh, et al., 2016). Fragmented international governance and conflicting national objectives constrain the development and implementation of unified and effective migrationhealth policies. In particular, policy approaches have not kept pace with growing challenges associated with the volume, speed, diversity, and disparity of modern migration flows and do not sufficiently address the existing health inequities, gaps in social protection, and determining factors of migrant health including barriers to access health services, goods, and facilities. (WHO, 2010, p. 43; also p. 44; also MacLean and Brown, 2009, p. 14) This situation also exacerbates health-security concerns. Health security concerns Health and security are related in multiple ways, from bioterrorism and pandemics to disruptions of public services and law and order and weakened military

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mental anguish, and loss of life (McMichael, Barnett, and McMichael, 2012, pp. 649, 651; Carballo, Smith, and Pettersson, 2008, p. 33).

Box 7.1 Rural-urban migration in Bangladesh following Cyclone Aila in 2009 “When Cyclone Aila hit the coast of Bangladesh in May 2009, water swelled over embankments along the Kholpetua river. The home Sirajul Islam shared with his wife and four children in Kolbari village was flooded, along with the single acre he used to raise shrimp. They left for Shyamnagar town, 15km away, where for four months he made 300–400 taka a day ($4–5) driving a rented motorbike. When the floodwater subsided, his field was too salty for shrimp. Village buildings were flattened and there was no fresh water to drink. So in 2011, the family went to seek their fortune in the capital Dhaka. ‘The cyclone had broken my economical backbone by destroying everything,’ says Islam. ‘If there had not been such a big cyclone, I would not have moved to Dhaka.’” Source: Darby (2017)

Looking toward the future: unhealthy and healthy responses to climate migrants Scientists agree that climate change in conjunction with other contributors will result in growing population displacement and migration (Nansen Initiative, 2015, p. 8). Sea-level rise alone threatens to generate millions of transnational climate migrants – especially from low-income countries where infrastructure is of poor quality and resources are not available to build seawalls and restore and raise buildings (Goodell, 2017, pp. 220–221, 231; Chan, 2017, p. 193; E. Dickenson, 2017, pp. 120–121; Ferris, Cernea, and Petz, 2011, p. 11). Although the Pacific region is responsible only for a tiny fraction of global GHG emissions, small-island states face some of the most severe migration pressures associated with climatic change (Ferris, Cernea, and Petz, 2011, pp. 3, 5, 19). The number of people vulnerable to sea-level rise continues to grow in the face of population growth, in-migration to coastal cities, land subsidence, storm surges, and small-island encroachments (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 50–53; Griggs, 2018; Kelman, 2008). In The Water Will Come, Jeff Goodell (2017, pp. 178, 13–14) looks ahead and asks, “What do rich industrialized nations like the United States and the European Union owe them?” “Will we [the North] welcome people who flee submerged coastlines and sinking islands – or will we imprison them?” As Mohamed Nasheed, former Maldives President, challenged the leaders of wealthy Northern GHG-emitting countries,

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‘You can drastically reduce your greenhouse-gas emissions so that the seas do not rise so much. . . . Or, when we show up on your shores in our boats, you can let us in. . . . Or, when we show up on your shores in our boats, you can shoot us. You pick.’ (Cited in ibid., pp. 187–188)13 The magnitude of the dilemma is mind-boggling when the prospective numbers of climate migrants is superimposed against the current political climate in Northern countries of antipathy toward admitting persons desperate to land on firm ground (Mavroudi and Nagel, 2016, p. 145; also see Kelman, 2008) and viewed alongside the lack of measurable progress across the planet in meeting essential emission-reduction goals (Plumer and Popovich, 2017a). The challenge of reducing the vulnerability of (particularly poverty-stricken) populations and societies to the impacts of climate change necessitates urgent action (Uitto and Shaw, 2006, p. 94; Heine and Petersen, 2008, p. 48) that engages future preparation. Proactive investment in protective-adaptation measures, including planning and training initiatives, is cost-effective over the long term due to reductions in displacement, mobility, resettlement, deaths, disease, and disabilities. The most promising approaches to climate adaptation incorporate community-centered methods, local-government-capacity strengthening, and multi-sectoral/multi-stakeholder partnerships (Uitto and Shaw, 2006, pp. 97–101; Heine and Petersen, 2008, pp. 48–49).14 In partnered contexts, it is important that adaptation planning resolve governance and coordination issues in advance, particularly “who should most usefully tackle which area, with which risk management intervention” (Heine and Petersen, 2008, pp. 48, 50).

The role of migration in climate change adaptation and mitigation In some last-resort circumstances, it will be necessary to facilitate climate migration in an effort to “enhance well-being and maximize social and economic development in both the places of origin and destination” (McMichael, Barnett, and McMichael, 2012, p. 652; also Bardsley and Hugo, 2010, p. 239). Along with self-interest, Earth’s principal GHG emitters have a moral responsibility for assisting climate migrants (McMichael, Barnett, and McMichael, 2012, p. 652). When properly planned and executed as an adaptive response to climate change, “the move to a new location can alleviate health deficits from undernutrition or freshwater shortages, avoid the physical dangers of extreme weather events and degraded physical environments, and enhance access to medical facilities” (McMichael, Barnett, and McMichael, 2012, p. 648; also Ferris, Cernea, and Petz, 2011, p. 26). Adaptive policies and practices that address the flow of environmental migrants “must not lose sight of the positive potential of human mobility” (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 95, 119). People often “keep their assets in more than one place” and temporary migration can allow a family

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to supplant lost incomes and resources (Heine and Petersen, 2008, p. 50). In the face of the new threats involving frequent hazard encounters, the spread of infectious disease, food insecurity, and clean water unavailability associated with climate change, supported migration to protected areas can diminish health risks and facilitate access to health services (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 87). The “healthy” response to actual and prospective climate migration involves contextually applied adaptation polices that help build resilience and place demographically sensitive health concerns at the center of action (McMichael, Barnett, and McMichael, 2012, pp. 647, 650–651; Dankelman, et al., 2008). The vulnerability of climate migrants is reduced and the health and social costs of relocation minimized by allowing adequate time for community consultations and planning, paying compensation at a level equal to the standard of housing and materials in the host community, ensuring that the money and resources made available to assist communities to relocate is spent on those communities, . . . employing the people being moved wherever labor is required, and providing support for housing, health services, mental health services, employment, and education. (McMichael, Barnett, and McMichael, 2012, p. 651)15 Successful resettlement will not be cheap (Bardsley and Hugo, 2010, p. 256). Adequate funding needs to be secured to ensure that relocation and other climate-change-adaptation measures will be addressed in an ethically responsible and healthy manner. Migrants and their diaspora members can play critical roles in adapting to climate-change dislocations. Particularly valuable are strategies that integrate environmental migrants and their diasporas into sustainable-development initiatives (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 95, 122–123; Uitto and Shaw, 2006, p. 98). Diaspora-fund transfers offer a promising opportunity in this connection. Legal protections and financing for adaptive environmental migration through climate funds and diaspora contributions constitute important components of sustainable-development initiatives (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 104–109, 111–115). For instance, transnational mobility can inspire “investment by migrants and diasporas into ecological practices, through remittances channeled into adaptation projects – notably land rehabilitation and reforestation – or through the acquisition of capabilities, expertise, and new skills that benefit communities of origin” (ibid., p. 119).16 Diasporas also can play decisive roles in climate-change-mitigation initiatives. Transnationally networked non-state actors no longer wait for governments to implement international agreements or to reform policies. Among their climatemitigation initiatives, diaspora members can become involved in addressing the contextual influences that shape household-consumption practices in places of origin. Their words, deeds, and resource transfers impact local decisions regarding

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“the purchase, use, and disposal of personal and household products” (Stern, 2000, pp. 409–410, 421), including automobiles and appliances, that produce GHG emissions. Diaspora transnationals also bring valuable skills and commitment to sending-country climate-mitigating projects involving energy efficiency, renewable energy, and transportation.17 The concluding section to this chapter shows that migration plays out in unexpected and potentially helpful ways in terms of climate-change mitigation and adaptation. Northern diasporas offer a fertile and diverse source of expertise, networks, and political savvy from which to launch engagements that will introduce and inspire climate-sustaining actions in the South. Transmigrants have constituted a key overlooked and underestimated piece in the emission-reduction puzzle. Chapter 8 expands the transmigration picture by tying in health education and service.

Notes 1 Elsewhere, in the face of long-term drought with no end in sight, millions of Iranians are on the move to provincial towns and cities (Sengupta, 2018b; also see Morrissey, 2008). In East Africa, prolonged drought has forced millions of pastoralists and rural dwellers into protracted conditions of “severe food insecurity” (Sengupta, 2018a). 2 “Chai Jing's review: Under the Dome – Investigating China’s Smog.” www.youtube. com/watch?v=T6X2uwlQGQM. 3 Under the Dome emphasizes coal-generated pollution. Still missing in China are compelling framings that target the consumer demand and motor-vehicle operations underlying air pollution and GHG emissions. Appeals to people’s health concerns offer particularly promising avenues for controlling and reducing per capita emissions because they convincingly transform visible and tangible air pollution into compelling personal motivations for reduced consumption of material goods and diminished vehicle use. On the health and environmental benefits of biking in urban China, see Koehn (2007, pp. 123–126). 4 When attributing national responsibility for carbon emissions, the entire carbon footprint, including suppliers and end consumers, overseas resource extraction and transportation, population size, and migrant absorption, needs to be incorporated. Elsewhere (Koehn, 2016, pp. 28–35), I employ such a full-accountability analysis to show that attribution arguments do not provide a favorable diplomatic pathway for China to pursue. 5 At the international level, the void is attributable to the Trump Administration’s antipathy toward climate actions. Subnational governments in the United States and elsewhere also have filled part of the GHG-emissions-leadership void through local actions and international collaborations (see Koehn, 2010; Schlossberg, 2017). 6 In 2018, the central government of China suspended production of more than 500 vehicle models that did not meet its fuel-economy standards (Tabuchi, 2018). 7 Delhi officials found it necessary for health reason to close schools in November 2017 due to hazardous pollution levels (Schultz, Kumar, and Gettleman, 2017) and, for nearly two weeks during that same month, Lahore, Pakistan, was “like one huge airport smokers’ lounge.” In 2015, nearly 60,000 Pakistanis died from toxic air particles (Zahra-Malik, 2017). 8 At current rates of warming, residents of cities in Iran will face similar problems (Sengupta, 2018b). 9 See Box 7.3 (“Will Hong Kong Sink under the Sea?”) in Chan (2017, p. 192). 10 See the IOM’s definition of environmental migrants found in Ionesco, Mokhnacheva, and Gemenne (2017, p. 3). Following the legal practice applied in determining

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whether someone is an official Convention refugee, climate change need not be the main reason responsible for the displacement of someone defined as a climate or environmental migrant (see Dun and Gemenne, 2008, p. 10). As James Morrissey (2008) shows in the case of Ethiopian highlanders stressed by drought, people consider a range of individual, environmental, and structural factors when “calculating the relative advantages of moving against the relative advantages of remaining behind.” Most of these movers are likely to join the ranks of the internally displaced population. The risk that mass environmental displacements will result in violent conflict is heightened when linked to existing tensions and failed policies (Ionesco, Mokhnacheva, and Gemenne, 2017, pp. 82–83). For insights regarding a successful decentralized community-based adaptation project in Mozambique that includes raising awareness among young people through curricular integration and a “‘people-centred early warning system’ based on local knowledge, customs, and cultural values,” see Heine and Petersen (2008, pp. 48–49). The remaining challenge in this case is “constantly maintaining people’s awareness of climate risks and the use of disaster preparedness” (ibid., p. 49). The additional insights regarding sustainable-relocation approaches presented in Chapter 3 also are applicable in the context of climate-change adaptation. In addition, “innovative mechanisms could be established to multiply their effects through complementary funds or to reorient them towards local development and climate change adaptation initiatives, while also involving the recipients of these transfers” (Ionesco, Mokhnacheva, and Gemenne, 2017, p. 104; also see p. 105). For a detailed discussion of the emission-mitigating roles and opportunities available in Mainland China to Chinese diaspora transnationals, see Koehn (2006, pp. 381–402).

References Adger, W. Neil.; and 12 co-authors. 2001. “Asia: Contribution of Working Group II to the Third Assessment Report of the Intergovernmental Panel on Climate Change.” In Climate Change 2001: Impacts, Adaptation, and Vulnerability, edited by James J. McCarthy, Osvaldo F. Canziani, Neil A. Leary, David J. Dokken, and Kasey S. White. Cambridge: Cambridge University Press. Pp. 533–590. Albeck-Ripka, Livia. 2017. “Why Lost Ice Means Lost Hope for Inuit Village.” New York Times, 27 November, p. A6. Andrews, Steven Q. 2008/2009. “Seeing through the Smog: Understanding the Limits of Chinese Air Pollution Reporting.” China Environment Series 10:5–29. Bardsley, Douglas K.; and Hugo, Graeme J. 2010. “Migration and Climate Change: Examining Thresholds of Change to Guide Effective Adaptation Decision-Making.” Population and Environment 32:238–262. Bell, Michelle L.; and Samet, Jonathan M. 2005. “Air Pollution.” In Environmental Health: From Global to Local, edited by Howard Frumkin. Hoboken, NJ: Jossey-Bass. Pp. 331–361. Blackburn, Sophie; and Marques, Cesar. 2013. “Mega-Urbanisation and the Coast.” In Megacities and the Coast: Risk, Resilience and Transformation, edited by Mark Pelling and Sophie Blackburn. London: Routledge. Pp. 1–21. Bradsher, Keith. 2009. “American Officials Press China on Efforts to Curb Greenhouse Gases.” New York Times, 16 July, p. A10. Bryner, Gary; and Duffy, Robert J. 2012. Integrating Climate, Energy, and Air Pollution Policies. Cambridge, MA: MIT Press.

Climate change, health, and migration

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Buckley, Chris. 2014. “China’s Plan to Limit Coal Use Could Spur Consumption for Years.” New York Times, 15 July, p. A6. Buckley, Chris; and Wu, Adam. 2017. “Enduring China’s Pollution with Masks, Filters.” New York Times, 7 January, p. A4. Cao, Lige; Gemmer, Marco; and Jiang, Tong. 2012. “Adaptation to Climate Change in China: Policy, Action, and Progress.” In China’s Climate Change Policies, edited by Weiguang Wang and Guoguang Zheng. London: Routledge. Pp. 58–75. Carballo, Manuel; Smith, Chelsea B.; and Pettersson, Karen. 2008. “Health Challenges.” Forced Migration Review 31 (October):32–33. Chan, Emily Ying Yang. 2017. Public Health Humanitarian Responses to Natural Disasters. London: Routledge. Chan, Lai-Ha; Chen, Lucy; and Xu, Jin. 2012. “China’s Engagement with Global Health Diplomacy: Was SARS a Watershed?” In Negotiating and Navigating Global Health: Case Studies in Global Health Diplomacy, edited by Ellen Rosskam and Ilona Kickbusch. London: World Scientific. Pp. 203–220. Chiu, Kong; Lei, Yu; Zhang, Yanshen; and Chen, Dan. 2007. “Breathing Better: Linking Energy and GHG Reduction to Health Benefits in China.” China Environment Series 8:117–122. Costello, Anthony; and 28 co-authors. 2009. “Managing the Health Effects of Climate Change.” Lancet 373:1693–1733. Crisp, Nigel. 2016. One World Health: An Overview of Global Health. Boca Raton, FL: CRC Press. Cumming, Ayden; and Layne, Davina. 2013. “Shanghai, China.” In Megacities and the Coast: Risk, Resilience and Transformation, edited by Mark Pelling and Sophie Blackburn. London: Routledge. Pp. 231–235. Dankelman, Irene; Alam, Khurshid; Ahmed, Wahida B.; Gueye, Yacine D.; Fatenia, Naureen; and Mensah-Kutin, Rose. 2008. “What It Means for Women.” Forced Migration Review 31 (October):56. Darby, Megan. 2017. “What Will Become of Bangladesh’s Climate Migrants?” Climate Home News, 14 August. Dickenson, Elliot. 2017. Globalization and Migration: A World in Motion. Boulder, CO: Rowman & Littlefield. Dun, Olivia; and Gemenne, Francois. 2008. “Defining ‘Environmental Migration’.” Forced Migration Review 31 (October):10–11. Ferris, Elizabeth; Cernea, Michael M.; and Petz, Daniel. 2011. On the Front Line of Climate Change and Displacement: Learning from and with Pacific Island Countries. Washington, DC: Brookings Institution. Friedman, Thomas L. 2013. “Too Big to Breathe?” New York Times, 6 November, p. A29. Gillis, Justin. 2017a. “Antarctic Dispatches.” New York Times, 20 May, pp. A11–A12. Gillis, Justin. 2017b. “World’s Unity on Warming Pivots on U.S.” New York Times, 1 June, p. A8. Gomez-Echeverri, Luis; Chen, Minpeng; Cui, Xueqin; Sha, Fu; Ke, Wang; and Wang, Weili. 2010. China and a Sustainable Future: Towards a Low Carbon Economy and Society. UNDP China Human Development Report 2009/10. Beijing: China Publishing Group Corporation. Goodell, Jeff. 2017. The Water Will Come: Rising Seas, Sinking Cities, and the Remaking of the Civilized World. New York: Little, Brown. Greenstone, Michael. 2018. “Four Years after Declaring War on Pollution, China Is Winning.” New York Times, 14 March, p. A8.

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Griggs, Troy. 2018. “Sea Is Rising, and the Land Is Sinking.” New York Times, 8 March, p. A20. Guo, Owen. 2015. “City Choking on Cars Longs for Bikes Return.” New York Times, 12 November, p. A6. Han, Mukang; Hou, Jianjun; and Wu, Lun. 1995. “Potential Impacts of Sea-Level Rise on China’s Coastal Environment and Cities: A National Assessment.” Journal of Coastal Research 14 (Winter):79–95. Heine, Britta; and Petersen, Lorenz. 2008. “Adaptation and Cooperation.” Forced Migration Review 31 (October):48–50. Hernandez, Javier C. 2017. “Climate Change Worsens China Smog, Studies Say.” New York Times, 25 March, p. A10. Hu, Angang. 1995. China’s Environmental Issues. In China as a Great Power: Myths, Realities and Challenges in the Asia-Pacific Region, edited by Stuart Harris and Gary Klintworth. New York: St. Martin’s. Pp. 328–341. Huang, Jialing; and Yang, Z. Janet. 2017. “Risk, Affect, and Policy Support: Public Perception of Air Pollution in China.” Asian Journal of Communication 28 (3):281–297. DOI: 10.1080/01292986.2017.1386220 Ionesco, Dina; Mokhnacheva, Daria; and Gemenne, Francois. 2017. The Atlas of Environmental Migration. London: Routledge. Ives, Mike. 2017. “Study Finds Dire Effects from a Tad More Heat.” New York Times, 9 June, p. A7. Jahn, Heiko J.; Kraemer, Alexander; Chen, Xiao-cui; Chan, Chuen-yu; Engling, Guenter; and Ward, Tony J. 2013. “Ambient and Personal PM2.5 Exposure Assessment in the Chinese Megacity of Guangzhou.” Atmospheric Environment 74:402–411. Kai, Ma. 2007. PRC Climate Change Program. Beijing: National Development and Reform Commission. [English version]. Kelman, Ilan. 2008. “Island Evacuation.” Forced Migration Review 31 (October):20–21. Koehn Peter H. 2006. “Fitting a Vital Linkage Piece into the Multidimensional Emissionsreduction Puzzle: Nongovernmental Pathways to Consumption Changes in the PRC and the USA.” Climatic Change 77:377–413. Koehn, Peter H. 2007. “Back to the Future: Bicycles, Human Health, and GHG Emissions in China.” China Environment Series (9):123–126. Koehn, Peter H. 2010. “Climate Policy and Action ‘Underneath’ Kyoto and Copenhagen: China and the USA.” Wiley Interdisciplinary Reviews (WIREs): Climate Change 1 (March/ April):405–417. Koehn, Peter H. 2016. China Confronts Climate Change: A Bottom-up Perspective. London and New York: Routledge. Leonhardt, David. 2017. “The Storm That Humans Helped Cause.” New York Times, 29 August, p. A27. Li, Jian. 2013. “China and Climate Change: Environmental Impacts, Human Security, and Migration Policies and Actions.” In Climate Change, Sustainable Development, and Human Security: A Comparative Analysis, edited by Dhirendra K. Vajpeyi. Lanham, MD: Lexington Books. Pp. 111–138. Liu, Haiying. 2009. “The Impact of Climate Change on China.” In The China Environment Yearbook, Volume 3, edited by Dongping Yang. Leiden, NL: Brill. Pp. 81–97. Lu, Xiaoqing; and Gill, Bates. 2007. “Assessing China’s Response to the Challenge of Environmental Health.” China Environment Series 9:3–15. Makinen, Julie. 2014. “China’s Battle Plans in War on Pollution under Scrutiny.” Missoulian, 14 September, p. A11.

Climate change, health, and migration

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Martens, Susan. 2007. “Public Participation with Chinese Characteristics: Citizen Consumers in China’s Environmental Management.” In Environmental Governance in China, edited by Neil T. Carter and Arthur P.J. Mol. London: Routledge. Pp. 63–82. Mavroudi, Elizabeth; and Nagel, Caroline. 2016. Global Migration: Patterns, Processes, and Politics. London: Routledge. McCracken, Kevin; and Phillips, David R. 2017. Global Health: An Introduction to Current and Future Trends. London: Routledge. McMichael, Anthony J. 2013. “Globalization, Climate Change, and Human Health.” New England Journal of Medicine 368:1335–1343. McMichael, Celia; Barnett, Jon; and McMichael, Anthony J. 2012. “An Ill Wind? Climate Change, Migration, and Health.” Environmental Health Perspectives 120, No. 5 (May): 646–654. Minter, Adam. 2015. “Clearing Skies.” Sierra Magazine, March/April. www.sierraclub.org/ sierra/2015-2-march-april/feature/clearing-skies#5; accessed 25 February 2015. Morrissey, James. 2008. “Rural-Urban Migration in Ethiopia.” Forced Migration Review 31 (October):28–29. Nansen Initiative. 2015. Global Consultation Conference Report: Geneva, 12–13 October 2015, Geneva. https://nanseninitiative.org; accessed 21 October 2107. Paterson, Matthew. 2000. “Car Culture and Global Environmental Politics.” Review of International Studies 26:253–270. Pierre-Louis, Kendra. 2018. “Antarctica Is Melting at a Much Faster Pace.” New York Times, 14 June, p. A13. Plumer, Brad; and Popovich, Nadja. 2017a. “Here’s How Far the World Is from Meeting Its Climate Goals.” New York Times, 11 November, p. A9. Plumer, Brad; and Popovich, Nadja. 2017b. “Tracking Possible Trajectory of a World of Sweltering Days.” New York Times, 23 June, p. A10. Porter, Eduardo. 2014. “The Benefits of Easing Climate Change.” New York Times, 24 September, pp. B1, B4. Porter, Gareth; Shi, Han; and Zhao, Shidong. 2003. Energy and Environment Outcome Evaluation. Beijing: UNDP China. Qi, Ye (ed.). 2013. Annual Review of Low-Carbon Development in China (2011–2012). China Research Perspectives on the Environment Series, Volume 2. Leiden, NL: Brill. Qian, Jingling; Finamore, Barbara; and Clegg, Tina. 2003. “Fuel Cell Vehicle Development in China.” Sinosphere Journal 6 (1):34–40. Samet, Jonathan M.; and Zhang, Junfeng. 2014. “Climate Change and Health.” In Routledge Handbook of Global Public Health in Asia, edited by Sian M. Griffiths, Jin Ling Tang, and Eng Kiong Yeoh. London: Routledge. Pp. 281–298. Schlossberg, Tatiana. 2017. “Governors and Mayors Plan to Address Climate Change Even Without Federal Help.” New York Times, 20 December, pp. D1, D3. Schultz, Kai; Kumar, Hari; and Gettleman, Jeffrey. 2017. “India Closes 4,000 Schools Over Dirty Air.” New York Times, 9 November, p. A5. Sengupta, Somini. 2018a. “In Horn of Africa, Drought Is the New Normal.” New York Times, 12 March, pp. A1, A7. Sengupta, Somini. 2018b. “Warming, Water Crisis, then Unrest: Iran Fits a Pattern.” New York Times, 19 January, p. A4. Shapiro, Judith. 2012. China’s Environmental Challenges. Cambridge, UK: Polity Press. Stern, Paul C. 2000. “Toward a Coherent Theory of Environmentally Significant Behavior.” Journal of Social Issues 56 (3):407–424.

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Stockholm Environment Institute [SEI]. 2002. China Human Development Report 2002: Making Green Development a Choice. Oxford: Oxford University Press. Suri, Arjun; Weigel, Jonathan; Messac, Luke; Basilico, Marguerite T.; Basilico, Matthew; Hanna, Bridget; Keshavjee, Salmaan; and Kleinman, Arthur. 2013. “Values and Global Health.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 245–286. Tabuchi, Hiroko. 2018. “China Halts Production of Cars Seen as Inefficient.” New York Times, 3 January, p. B2. Tanner, Thomas; and Horn-Phathanothai, Leo. 2014. Climate Change and Development. London: Routledge. Tharoor, Ishaan. 2015. “China’s Biggest Viral Video Right Now Is This Two-Hour-Long Documentary on Pollution.” Washington Post, 3 March. Uitto, Juha I.; and Shaw, Rajib. 2006. “Adaptation to Changing Climate: Promoting Community-Based Approaches in the Developing Countries.” SANSAI: An Environmental Journal for the Global Community 1:93–107. United Nations Environment Programme (UNEP). 2013. China’s Long Green March. Nairobi: UNEP. United Nations Human Settlements Programme (UNHSP). 2011. Cities and Climate Change: Global Report on Human Settlements 2011. London: Earthscan Publications. Uretsky, Elanah. 2016. Occupational Hazards: Sex, Business, and HIV in Post-Mao China. Stanford, CA: Stanford University Press. Vandenbergh, Michael P. 2008. “Climate Change: The China Problem.” Southern California Law Review 81:905–950. Watts, Nick; and 44 co-authors. 2015. “Health and Climate Change: Policy Responses to Protect Public Health.” Lancet:1861–1914. Wong, Andromeda H.S.; and Wong, Tze Wai. 2014. “Air Pollution: The Public Health Challenges.” In Routledge Handbook of Global Public Health in Asia, edited by Sian M. Griffiths, Jin Ling Tang, and Eng Kiong Yeoh. London: Routledge. Pp. 310–328. Wong, Edward. 2013a. “Early Deaths Linked to China’s Air Pollution Totaled 1.2 Million.” New York Times, 2 April, p. A9. Wong, Edward. 2013b. “Response to a City’s Smog Points to a Change in Chinese Attitudes.” New York Times, 25 October, p. A12. Wong, Edward. 2014. “China to Reward Cities and Regions Making Progress on Air Pollution.” New York Times, 14 February, p. A9. Wong, Edward. 2015a. “Fines Total $26 Million for Polluters in China.” New York Times, 1 January, p. A8. Wong, Edward. 2015b. “Report Finds Chinese Cities Fail to Meet Air Standards.” New York Times, 22 April, p. A6. Wong, Edward. 2016a. “Burned Coal Is Deadliest Part of China’s Polluted Air, Study Says.” New York Times, 18 August, p. A10. Wong, Edward. 2016b. “Wrenching Resettlement in China, with More Likely to Come.” New York Times, 25 October, pp. A1, A10. Wong, Edward. 2017. “‘Irrational’ Coal Plants May Hamper China’s Climate Change Efforts.” New York Times, 7 February. Wong, Edward; and Buckley, Chris. 2015. “China Premier Vows to Get Tougher on Smog.” New York Times, 16 March, p. A8.

Climate change, health, and migration

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Yang, Ming; and Yu, Xin. 2015. “Energy Efficiency to Mitigate Carbon Emissions: Strategies of China and the USA.” Mitigation and Adaptation Strategies for Global Change, 4 May. DOI: 10.1007/s11027-015-9657-9 Young, Andrea F. 2013. “Coastal Megacities, Environmental Hazards and Global Environmental Change.” In Megacities and the Coast: Risk, Resilience and Transformation, edited by Mark Pelling and Sophie Blackburn. London: Routledge. Pp. 70–99. Zahra-Malik, Mehreen. 2017. “Forecast for Lahore’s ‘Fifth Season’: A Blanket of Toxic Smog.” New York Times, 13 November, p. A11.

8

Where should we “move” from here? 21st-Century global-health education and service

Global health today is beset by massive practitioner shortfalls, particularly in Africa, and competence gaps that exacerbate transnational migration. In response to these voids, this concluding chapter affirms the case for robust transnational-competence (TC) education in North and South, for migrants as well as health practitioners – including community-health workers. In addition, symmetrical transnational partnerships are featured and innovative-health technologies that promise to enhance medical education and public-health capacity in the South are critically assessed. Prospects that committed and transnationally mobile volunteers can inspire and catalyze community-health gains in the South are explored in-depth. In this concluding discussion, mobility initiatives with the potential to advance global health receive considerable attention. We first consider the limitations, risks, and contributions of uncoordinated short-term medical missions and educational experiences. Then, launching a TC-equipped Global Health and Migration Corps is proposed and justified. The conclusion to Transnational Mobility and Global Health incorporates changing public-health and mobility ethics. How can we advance “Us before Me” ethics, the pursuit of solidarity, in the interests of individual and population health? As we move forward, respect for autonomy and community participation must be part of the ethical equation. Prospects for increased transnational-health equity are enhanced by analysis of social determinants and policy decisions, enforced international instruments, the integration of national with global health initiatives, symmetrical-research partnering, reverse learning, migrant-health advocacy, and collaborative and convincing evaluations of health outcomes and impacts.

Health-practitioner shortfalls and competence gaps Health coverage depends upon four interconnected conditions: availability, accessibility, acceptability (culturally and otherwise), and competence (Crisp, 2016, p. 8). Non-availability precludes access. Quality care requires both technical and interpersonal competence. And, as the prior chapters of this book have demonstrated, health-care providers need to devote increased, insight-informed, attention to issues of migrant health.

Introduction 15 The capability to migrate will not result in spatial movement “if people do not desire to do so” (Flahaux and De Haas, 2016, p. 4). The desire to migrate depends on “general life aspirations,” including health-care aspirations, and changing “perceptions of the extent to which these aspirations can be fulfilled ‘here’ and ‘there’” (Flahaux and De Haas, 2016, p. 4). Subjective perceptions that “there” offers better health-care opportunities differentially develop among persons with improved access to information and increased exposure to traditional and social media and advertising that emanates from the North (Flahaux and De Haas, 2016, p. 4). The framework for analysis applied in Transnational Mobility and Global Health recognizes that critical activated dimensions of mobility privilege and restrict health-seeking migration. In the interest of health promotion as well as other opportunities, “individuals, families, and communities use mobility in sometimes pre-emptive, often reactive, and other times more strategic fashion” (Lindley, 2014, p. 16; also Lindley and Hammond, 2014, p. 67). Philip Marfleet and Adam Hanieh (2014, p. 26) report that “for some migrants, changes that prompt their journeys are unwelcome or even threatening, and migration itself is undesired and dangerous; for others, change is positive, presenting new opportunities, including those offered by migration.” On stage, the migration dramas by NigerianAmerican playwright Mfoniso Udofia similarly “offer a moving and powerful corrective to the notion that what immigrants leave behind is always awful, and that what they find is always worth the trip” (Green, 2017, p. C1). Further, the international regime, political persecution and oppression, armed conflict, and border controls shape mobility options. The ability of individuals to relocate long distances and secure desired health benefits is contingent upon key upstream,36 midstream, and downstream behavioral and structural factors that are contextually present or absent (see McCracken and Phillips, 2017, pp. 70–72). Foremost among these conditioning enablers are class, transnational competence (see Koehn and Rosenau, 2010), and access opportunities (place, time, transport, and nation-state-reception policies).37 In all cases, moving “from latent to manifest mobilities is highly related to inequality structures” (Ohnmacht, Maksim, and Bergman, 2009, p. 13). Moreover, the health benefits and costs of transnational mobility are inequitably distributed at regional, national, and individual levels. Addressing the daunting and interconnected “now what” challenges of mobility and health, then, requires multifaceted attention to primary-, secondary-, and tertiary-prevention prospects (McCracken and Phillips, 2017, pp. 71–72).

Health and mobility issues of special global concern Individual-, family-, and community-health prospects associated with unequal population movements of different types (proactive and reactive, short-term and long-term, distant and proximate, recognized and undocumented) are of special interest in this book. Two recurring dynamics shaped the choice of the thematic cases selected for attention in the chapters that follow: (1) the presence of a robust and important transnational mobility-health interface that unmasks and

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professional-mobility circuits are well-developed and visible and Cuba has led the way in South-South ventures,2 North-South pathways remain undernourished and underdeveloped. In the sections that follow, we elaborate the essential components of a balanced and encompassing global system for the mutually beneficial exchange of health-care personnel: transnational-competence education, symmetrical partnerships, volunteer incentives, and a Global Health and Migration Corps (GHMC).

The role of transnational-competence education in North and South The urgent 21st-Century challenge facing educators at medical schools and nursing and public-health programs involves the need to prepare professionals who are capable of reducing the ethnic, class, and South-North disparities that currently prevail in health risks, access to beneficial advice and medical procedures, and treatment outcomes (see Smedley, Stith, and Nelson, 2003). Health-related professional education “has not kept pace with these challenges, largely because of fragmented, outdated, and static curricula that produce illequipped graduates” (Frenk, et al., 2010, p. 1923; also p. 1950). Concomitantly, high staff turnover in organizations that serve displaced persons, including UNHCR, means that younger, less-experienced personnel lack training in the inter-sectoral, policy, management, evaluation, and related skills needed to operate effectively (Martin, et al., 2017, p. 114). The interconnected nature of today’s health-care context with transnational dynamics awaits a prominent place in forward-looking interdisciplinary professional education (Lencucha and Mohindra, 2014, pp. 63–66). Migrant-health issues and mobile populations constitute a critical component of the needed redesigned of a continuing competency-based educational endeavor (Pottie, Hui, and Schneider, 2016, p. 300; Frenk, et al., 2010, p. 1951). Growing numbers of students enrolled in medical schools and health-related professional programs are recognizing the importance of developing skills that can be used when working with foreign-born and foreign-connected populations. Transnational-competence education (see Koehn and Rosenau, 2010), which improves upon cultural competence (Koehn and Swick, 2006; Chapter 4; Sears, 2012, p. 546) and stresses the identification and selection of advocacy roles, promises to provide a particularly valuable component in a proactive approach to advancing migrant health (see, for instance, Pottie and Gruner, 2016, pp. 337–338) and global health in North and South. The comprehensive set of analytic, emotional, creative, communicative, and functional skills that form the core of a transnational-competence curriculum (see Chapter 4 for details) promise to reinforce new initiatives and redirect traditional medical-school and health education in ways that promote context-sensitive migrant health. This outcome is advanced by promoting competency in ethical reasoning (Cole, et al., 2013, pp. 148–149) and specifically addressing connections among poverty, inequality, displacement, discrimination, and health disparities in both North and South

Where should we “move” from here? 207 (see Koehn, 2006a; Koehn and Rosenau, 2010; Jogerst, et al., 2015, pp. 243–245; Lyon, Kim, and Farmer, 2008, p. 267; Johnson, et al., 2012, pp. 2034–2035; Howard, et al., 2011, p. 527; Crisp, 2010, p. 204; Illingworth, 2012, p. 200). Integrating a global perspective and “intercultural sensitivities” into “all courses and exercises” in Northern health-profession and interprofession (Jogerst, et al., 2015, p. 245) higher-education constitutes an important part of a revitalized and transformative TC-centered curriculum that graduates “enlightened change agents” (Frenk, et al., 2010, pp. 1948, 1952; also Johnson, et al., 2012, p. 2034).3 Instead of a narrow focus on clinical learning, prospective practitioners who will be addressing upstream, midstream, and downstream manifestations are best served by “the development of unique, broad-based, interprofessional global health competencies” (Melby, et al., 2016, p. 634). Participation in health-service endeavors in unfamiliar terrain can enhance the TC of Northern professional health-care givers who work with migrants and other vulnerable populations (Campbell, et al., 2011, p. 127). Furthermore, prospects for positive migranthealth outcomes are greatly enhanced when participants as well as providers are transnationally competent (Koehn, 2005a, 2005b, pp. 65–69; WHO, 2010, pp. 15, 66–67; Chapter 4). Integrating TC education in Southern as well as Northern higher-education institutions would constitute an important step forward. Too often, in healthprofession schools in the South, “instead of working competencies, production of health professionals is based on certification or Western medical standards. The result is a greater proportion of graduates focused on professional status and income generation, which further increases potential out-migration to wealthier countries” (Mullan, Panosian, and Cuff, 2005, pp. 27, 24, 145). Exceptionally, health education at Jimma University in Ethiopia already incorporates the important TC-analytic principles of learning from and collaborating with patients and communities and recognizing local needs based on context and circumstances (Crisp, 2010, pp. 13, 16; also see Koehn and Obamba, 2014, pp. 168–171; Sande and Ronald, 2008, pp. 180–181). The Latin American Medical School (LAMS) in Havana could take the lead in preparing Southern TC-qualified health workers. Since its opening in 1999, LAMS has graduated more than 30,000 doctors from 121 countries, including many from Africa (Crisp, 2016, pp. 147–148). LAMS’ focus on educating physicians from poor, remote, and excluded backgrounds (Crisp, 2016, p. 148) ideally situates the institution for preparing TC-qualified professionals who will provide health care to underserved communities in the South.

The role of symmetrical transnational partnerships and innovative health technologies The 21st-Century health of migrants and receiving populations hinges in large measure on transnational collaboration. Care seekers and care givers, along with policy makers, in both North and South “need win-win partnerships with pannational policies and mutual benefits for all sides” (Pottie, Hui, and Schneider,

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2016, p. 301; also Crisp, 2016, p. 191; Kerry, Auld, and Farmer, 2010, p. 1199). As Joel Samoff and Bedemi Carrol (2004, p. 115) have captured the concept, a partnership must involve a collaboration that can reasonably be expected to have mutual (though not necessarily identical) benefits, that will contribute to the development of institutional and individual capacities at both [multiple] institutions, and that is self-empowering, enabling both [all] partners to specify goals, chart [transformative] directions, create appropriate governance strategies, employ effective administrative routines, and focus human, material, and financial resources on high priority objectives. Universities populate the transcontinental partnerships that embody vast potential to improve health outcomes in North and South. Higher-education partnerships are intended to “coordinate activities, share resources, [and/] or divide responsibilities related to a specific project or goal” (Kinser and Green, 2009, p. 4). Higher-education institutions partner with other universities, foundations, ministries, national- and international-development agencies, private firms, NGOs,4 think tanks and other boundary organizations,5 communities, and local governments. For instance, with a launching grant to the University of KwaZulu-Natal from the Carnegie Foundation, the Center for HIV/AIDS Networking (HIVAN) “plays a central role in facilitating collaboration between civil society organizations, community sectors, public and private sector actors and higher education across South Africa and throughout the region” (Roberts, 2005, p. 12). Additionality, symmetry, and reciprocity In their ideal form, transnational higher-education partnerships (THEPs) embody “values and principles of mutual influence, equality, and reciprocal accountability” (Brinkerhoff, 2002, pp. 17–18, also pp. x, 14) and involve extended active engagement (Koehn and Obamba, 2014, p. 135; Sykes, 2014, p. e44). THEPs are of particular relevance to global health because governments and foundations channel hundreds of millions of dollars and euros to research and action projects that are initiated, carried out, and evaluated by universities (Fischer and Lindow, 2008, p. A22). Indeed, a number of bilateral-donor agencies that fund international-development assistance and scientific research have insisted that Northern researchers identify partners in the global South (Habermann, 2008). However, many universities in rich and poor countries remain insufficiently outward-looking; thus, they fail “to exploit the power of networking and connectivity for mutual strengthening” (Frenk, et al., 2010, p. 1950). This shortcoming is particularly noteworthy for primary-health care, where the urgent challenge is integrating local problem solving with “transnational flows of information, knowledge, and resources” (ibid.) in ways that reduce inequities and enhance population health. While transnational partnerships carry transaction costs, they can pool and share assembled essential resources, spread risks, and bring multiple perspectives

Where should we “move” from here? 209 and complementary core competencies to bear on health challenges. THEPs also enhance the reputation and social capital of participants and facilitate the leveraging of contributions and support from non-academic sources (Brinkerhoff, 2002, p. 3; Crossley, et al., 2005, p. 44; Hamann and Boulogne, 2008, p. 55). In these ways, THEPs bring “additionality” to human-capability and institutionalcapacity-building initiatives in both South and North. They offer universities one cost-effective way to respond to escalating demands for increased higher-education capacity and performance without diminishing quality (Johnstone and Marcucci, 2010, p. 26; Eckel and Hartley, 2011, pp. 199–200). Unsurprisingly, a survey of 82 North American academic institutions and 44 international partnering bodies provided evidence of mutual benefits and “near unanimous agreement . . . that global health partnerships are beneficial” (Muir, et al., 2016, pp. iv, 18). In the symmetrical THEP, participants recognize and appreciate that all partners bring something of value to the table (Ingram, 2004, p. xi; Obamba, Mwema, and Riechi, 2011, p. 3) and no single participant can unilaterally dictate relationship terms or only pursue self-interests. The ethics framework for medical research articulated by Médecins Sans Frontières (MSF) embraces these and other fundamental components of symmetrical transnational partnerships. Specifically, the MSF framework calls for involving the study community “through a consultative process in designing the research, in its implementation (advice on problems occurring during study, feedback of intermediate results) and in assessing how research results may be made beneficial” (Hussein and Upshur, 2013, p. 106). Attention should be devoted to developing the data-collection and data-analysis capabilities of Southern co-investigators and to providing health education and other sustainable community-wide benefits (ibid., p. 114). Upon completion of the joint research undertaking, partners should ensure that “relevant and appropriate” results are integrated into the local health system (ibid., p. 106).6 In addition to complementarity and equity, symmetrical THEPs embrace autonomy in the sense of freedom to determine the nature of reciprocal arrangements and “to select the ways in which interdependence .  .  . is established” (Rosenau, 1992, p. 3). At their roots, model THEPs are inspired by the imperative that “local needs require local prospects in global frameworks, and global challenges need global solutions that are locally acceptable” (Escrigas and Lobera, 2009, pp. 12–13). Because it incorporates many of the features of a symmetrical South-North THEP (see Koehn and Obamba, 2014, Chapters 3–7), the AMPATH (Academic Model Providing Access to Health Care) partnership merits considered attention in connection with prospects for advancing global health by addressing entrenched disparities.7 Indiana University-Purdue University, Indianapolis-Moi University Schools of Medicine partnership In 1989, the Indiana University School of Medicine in the United States entered into a formal partnership with Moi University School of Medicine based in

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Eldoret, Kenya. The partnership was part of a wider initiative to build human capabilities and institutional capacity at the newly created medical school at Moi University (AMPATH, 2009). At the turn of the new millennium, the Indiana University-Purdue University, Indianapolis (IUPUI)-Moi University partnership developed a comprehensive and integrated program in response to the HIV/ AIDS pandemic in Kenya. This collaborative program is known as the Academic Model Providing Access to Health Care, or AMPATH. The Moi-Indiana THEP explicitly integrates the tripartite missions of care, education, and research through a multi-agency, multidisciplinary, and holistic approach to health-care-capacity building. It emphasizes mutual benefit, complementarity, equity, and long-term mutual commitment to the partnership’s goals. The overall aim of the partnership is to develop health-care professionals capable of responding to emerging challenges of global health both in the United States and Kenya. Specific THEP objectives include building institutional capacity and human capabilities for health-care provision in both countries, undertaking joint curriculum development that will strengthen medical education and training at the partner universities, promoting collaborative medical research and fostering a sustainable-research environment, facilitating student and faculty exchange and mobility between Indiana University and Moi University, and developing distance-learning technologies and programs for medical education (AMPATH, 2009). In 2008, the partners expanded the AMPATH project as part of a major shift from the initial focus on HIV/AIDS treatment to a much wider spectrum of infectious diseases that incorporates the provision of household-economic and livelihood support. AMPATH now consists of multiple collaborative programs, including the HIV/AIDS Control Program, Orphans and Vulnerable Children Program, Maternal and Child Health Program, Home-Based Counseling and Testing Program, Primary Care and Disease Control Program, Family Preservation Program, Agriculture Program, Safe Water Program, Medical Education and Scholarships Program, Joint Research and Dissemination Program, Medical Records System, and Legal Aid Center Program (Indiana University, 2010). These programs cover a vast spectrum of projects, including training of medical professionals, building institutional capacity, strengthening medical-research and knowledge-production capacity, and supporting sustainable-economic livelihoods for local communities. The AMPATH THEP demonstrates best practice in symmetric and collaborative governance structures, operations, and management.8 Program leadership is shared between a North American field director and a Kenyan program manager. The AMPATH-research program is headed by two program coordinators, one from each partner university. To facilitate collaboration and symmetry, research is organized into nine working groups; each research project must have a principal investigator from North America and from Moi University. The Moi-IUPUI partnership manifests a range of distinctive features that promote symmetry, sustainability, and mutual benefit. First, leaders at the highest levels of both institutions are actively engaged with and supportive of the

16

Introduction

illuminates (2) the glocal health and well-being consequences of unequal mobility. Practical approaches to addressing the determinants of unequal mobility and health conditions are incorporated throughout the work. Migrant health, human rights, and the provision of humanitarian medicine emerge as core global health concerns that are treated in-depth in Chapters 2 through 4. Mobility impacts on the dynamic interaction of health, resilience, and sustainable development, along with the paradigm shift “from pathogenic to salutogenic thinking” (Astier, 2008, p. S10), receive attention in Chapter 5. The “fatal flow of expertise” also is unpacked in Chapter 5. South-South and South-North population movements capture the bulk of attention in light of their critical global implications for individual and population health. However, North-South mobility in search of health benefits (treated in Chapter 1) has a powerful conditioning impact on local opportunities and, therefore, must not be overlooked. The “two migration processes of [health-care] workers and patients cumulatively affect the ability of health systems to equitably and adequately deliver health care” (Walton-Roberts, 2015, p. 238). Patient mobility aka health tourism The first chapter of Transnational Mobility and Global Health is devoted to travel health and to health tourism, a practice of increasing popularity, particularly among wealthy Northerners and Southerners.38 Transnational care constitutes a growing manifestation of unequal mobility that merits attention in a book that aims to provide a comprehensive treatment of health and population movement. Patient transnational travel in search of health benefits constitutes the paramount focus of attention in Chapter 1. Although traveling to receive health care has a long history (Lunt, Horsfall, and Hanefeld, 2015, pp. 3–5), current medical tourism is quantitatively greater in terms of patient numbers and competing treatment sites at the same time that it is qualitatively challenged by unintegrated demand and supply developments (Lunt, Horsfall, and Hanefeld, 2015, p.  6). A conservative estimate holds that some five million international patients per year engaged in medical tourism by 2010, generating an estimated market value of $2.5 billion in treatment expenditures (Horsfall and Lunt, 2015, pp. 27–33). The increasingly popular global phenomenon of long-distance travel is associated with particular health challenges that require pre-departure, in-transit, and posttravel attention (Leder, et al., 2013). The market entry of low-income and middle-income countries has realigned the supply side. Patient-care enhancements, affordability,39 and the emergence of transplant tourism are strategies designed to increase the appeal of Southern treatments. Simultaneously, “the diffusion of surgical techniques and patient safety knowledge, combined with the circulations of clinicians who have trained within, or have experienced, overseas systems [has] facilitated the internationalization of techniques previously confined to Western nations” (Lunt, Horsfall, and Hanefeld, 2015, p. 7). Global governance of medical tourism remains to be seriously addressed, however.

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Several closely related practices drive innovative health-promoting technologies and approaches. The first involves foreseeing and mobilizing the synergistic relevance of diverse group perspectives in collective transboundary problem solving (Goleman, 1998, p. 27). In a deterritorialized world, “the new power of the imagination . . . is inescapably tied up with images, ideas, and opportunities that come from elsewhere” (Appadurai, 1996, p. 54). Diversity provides a “proven way to increase the randomness of concept combinations” (Johansson, 2004, p. 79). Because variegated perspectives create novel connections, the participation of diverse stakeholders in a common project “often triggers a new way to look at and contend with” problems and challenges (Bammer, 2005, p. 6). By expanding the pool of available alternatives, diversity enables teams to move beyond blockages or “sticking points” (Page, 2007, pp. 9–10, 16; Dreifus, 2008). Transnationally co-creative actors learn to reframe problems, to envision alternative resolutions, to advance the envisioning process (Cortes and Wilkinson, 2009, p. 29), and to leverage the rich potential inherent in multiple-perspective endeavors. The successful mixing and merging of dissimilar backgrounds and viewpoints can produce collective accomplishments that exceed the sum total of the separate contributions (Moran, Harris, and Moran, 2007, p. 229). A closely related innovative practice involves the (co-)envisioning of new paradigms, unmet needs, viable alternative futures, processes, and roles that are mutually acceptable among collaborators who possess diverse identities. Envisioning includes maintaining a future orientation, recreating and enriching personal and organizational outlooks (Cortes and Wilkinson, 2009, p. 18), engaging in creative accommodation, and perceiving opportunities for transboundary resource mobilization. What is imagined also must be translated into contextually viable action plans. The special challenge facing the transnationally active professional is to create one’s own transformative role when existing role definitions are loosely defined and/or unstable. Creating new interprofessional-role definitions “demands both imagination and an orientation toward the future” (Werdell, 1974, p. 290). Innovation is advanced by working across boundaries and barriers. Associates with the ability to tap into diverse socio-cultural and technical sources for inspiration will strengthen and/or reinforce the other dimensions of transboundary imagination. By frequenting boundaries where concepts from different fields clash, combine, and intersect with diverse human perspectives, interprofessionals will be more likely to perceive synergistic potentials, to envision transnationally acceptable alternatives, and to identify innovative and shared syntheses. Frans Johansson (2004, pp. 2, 16–17, 20–23, 46–47) calls this place the “Intersection” and refers to the resulting “explosion of remarkable innovations” as “the Medici Effect.” Possibilities range from integrating spatial data obtained from geographic-information-systems (GIS) technology with data collected through ethnographic inquiry (Janes, 2004, p. 467) to utilizing telemedicine tools creatively in providing transnational care (Renzaho, 2016, p. 185). Artificial intelligence (A.I.) provides a case in point:

Where should we “move” from here? 213 Imagine the role that A.I. might play during surgery . . . . a combination of smart software and specialized hardware could help surgeons focus on their strengths – traits like dexterity and adaptability – while keeping tabs on more mundane tasks and protecting against human error, fatigue, and distraction. . . . What’s left are the creative, intellectual, and emotional roles for which humans are best suited. (Li, 2018) Further breakthroughs in health-protecting applications of A.I. rest upon incorporating group perspectives that have been underrepresented to date and enriching the foundation of machine intelligence by connecting on interdisciplinary projects with social-science and humanities scholars (ibid). At the level of individual migrant-health promotion, creative practitioners initiate fruitful new connections among parts of the care seeker’s experience. This approach involves integrating the service user’s unique life context (physical and emotional experiences and institutional forces) and current placespecific environment (housing, social disorganization, transportation, etc.) in a tailored health-action plan. The petitioner’s own ideas, suggestions, resources, and ingenuity feature prominently in the mutually agreed-upon therapeutic plan. In a world of dynamic merging and mixing, creative approaches to managing demands for medical treatment and health protection include complementary integrations of distant and proximate biomedical, alternative, and ethnocultural explanatory frameworks and health-related practices. The ability to co-create informal transnational paths is particularly valuable because a substantial proportion of all health care is provided “outside the perimeter of the formal health care system” (Kleinman, Eisenberg, and Good, 1978, p. 251). Further, practitioners must be prepared to relate transnational physical and emotional conditions and experiences to approaches that effectively address promising social changes and policy alternatives (Waitzkin, 1991, pp. 9, 23). Such creative approaches incorporate multilevel and multilocational linkages of individual, socio-political, and ecological considerations. Thus, innovative care providers are called upon to construct a health-promotion action plan that includes societal reinforcement of linked physical/mental-health interventions.

Short-term Southern medical missions: volunteerism or voluntourism? The “extraordinary tradition” of Northern health-care givers volunteering to work in Southern places (Crisp, 2010, p. 206) continues and grows (Martiniuk, et al., 2012; Sykes, 2014, pp. e38, e41; Campbell, et al., 2011, pp. 124, 127).12 This unidirectional flow includes experienced professionals, “individuals who can provide only elbow grease” (Zuger, 2016), and, somewhere in between in terms of preparation and competence, Northern pre-health-profession and medical students who perceive unique opportunities to engage in “moral professional practice” (see McCall and Iltis, 2014, p. 287).

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Short-term medical missions vary widely in personnel size and composition, budget, organizational structure, objectives, number of and quality of undertakings, and duration (Maki, et al., 2008; Sykes, 2014, p. e40; Garbern, 2009/2010, p. 41). In the United States, “short-term rotations, or clinical electives, consisting of six to eight weeks of clinical practice in a so-called ‘resource-poor’ setting have become enormously popular across medical schools and specializations” (Brada, 2017, p. 40; also Martiniuk, et al., 2012; Langowski and Iltis, 2011, p. 72; Redwood-Campbell, et al., 2011; Melby, et al., 2016, p. 633). Who benefits from these transnational population movements on behalf of global health? Do such short-term ventures amount to more than voluntourism? The motivations for sustained volunteerism include the psychological and emotional rewards that accompany opportunities to serve the disadvantaged and the chance to gain career-enhancing experience (Melby, et al., 2016, p. 633; Withers, Browner, and Aghaloo, 2013, p. 374; Brada, 2017; McCall and Iltis, 2014, p. 287; Sykes, 2014, p. e41; Campbell, et al., 2011, p. 125). Some doctors opt to participate on an overseas “surgical or fistula tourism” mission “to hone skills and see conditions which they might not otherwise encounter” (Martiniuk, et al., 2012; also Brada, 2017). Providing full-spectrum and follow-up care is problematic in short-term visits (see Garbern, 2009/2010, p. 42)13 and there often is little interest in delivering preventative programs (Martiniuk, et al., 2012). In some situations, such as the post-2010 earthquake in Haiti, efforts by health professionals to provide aid “placed additional strain on local resources” (Langowski and Iltis, 2011, p. 73; also Crump and Sugarman, 2008, p. 1457). Nevertheless, short-term and long-term professional volunteer placements need to be distinguished from brief travel-abroad practical experiences that are combined with a holiday or adventure, one of the fasted growing forms of tourism. Voluntourism “has become popular in many countries, including the USA, Canada, Singapore, Australia, New Zealand and throughout Western Europe” (McCall and Iltis, 2014, p. 286). According to Rebecca Tiessen (2018, p. 16), such voluntourism is popular among all age groups because it is something that can take place during study breaks, annual leave, or other holiday time. . . . For some, the short trip to volunteer is the adventure or holiday in and of itself. The education and training of patients and local providers, a crucial dimension of sustainable impact, can receive insufficient attention during any short-term medical-service visit (Chapin and Doocy, 2010, p. 51; Maki, et al., 2008; Sykes, 2014, p. e41; Garbern, 2009/2010, pp. 41, 43). However, some organizations that recruit volunteer global health professionals provide education as their core contribution. At considerable cost, for instance, Operation Smile brings Southern physicians to its Virginia headquarters annually for training in cleft-repair surgery (Wolfberg, 2006, p. 444; Campbell, et al., 2011, pp. 124–125). Orbis, the Flying

Where should we “move” from here? 215 Eye Hospital, has fortified an entire airplane with all the operating equipment and video capabilities needed to train local counterpart ophthalmologists in various surgical procedures that are mentored live by a team of skilled professionals (Wolfberg, 2006, p. 444).14 For Orbis, “training is at the very heart of everything we do.” In 2016, Orbis participants (including online mentoring and long-term country engagements) completed over 40,000 trainings for doctors, nurses, and other health workers.15 A number of sources document the mutual value of contemporary volunteer contributions to community health by young people. One of the most impressive accounts is Doing Development in West Africa: A Reader By and For Undergraduates, edited by Charles Piot (2016). Doing Development in West Africa showcases the Togo-centered development initiatives, research, and reflections of Duke University undergraduate students with diverse backgrounds and majors. Contributions and challenges, strengths and limitations, joys and frustrations, find articulate and compelling voices in this forthright treatment of small-scale student projects that address health and medicine16 and youth flight. For instance, Alexandra Middleton contributes an in-depth explication of the multiple ways (socially, spiritually, and relationally as well as physically) that the Kabre’s local medical system heals. In a chapter devoted to her research in Togo’s rural villages, Stephanie Rotolo documents how “new biomedical tools and diagnostics are used alongside local traditions at increasing rates” (ibid., p. 77) and identifies ways in which traditional healing and biomedical practices complement each other, filling in gaps where each system reaches its limits (of remedy and explanation) (ibid., p. 68). Kelly Andrejko explores the interplay of herbal and biomedical remedies in the capital city of Lomé. Caitlin Moyles presents a detailed account of her struggles and hard work to establish a sustainable creative-writers’ society in the small village of Farendé. Ultimately, the writers’ society is modestly successful and becomes part of an “enticing package” for mobility-inclined youth alongside Emma Smith’s micro-finance initiative and another student’s computer-typing classes. Even when accompanying faculty facilitators have a reservoir of community trust and good will to draw upon, the challenges of prior preparation, immersion in the field, and post-field mentoring require careful attention, particularly when untested and minimally prepared Northern youth are expected to make useful contributions in unfamiliar Southern contexts over perhaps eight weeks.17 In the Duke case, the program embeds high expectations among cohorts of students who have not completed their first-degree studies, are only “encouraged” to take courses on African culture and politics and to enroll in preparatory independent studies prior to departure, are asked to consult (if possible) with those “who have gone before,” and find themselves working independently for the most part in the field on merely “brainstormed” projects (ibid., p. 10) with short time frames available. This is a recipe that, in most circumstances, should not be attempted. Yet, Doing Development in West Africa shows that it can satisfy when all facilitating factors (including host receptivity) are aligned and, therefore, partly silences the skeptics. To minimize the

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risk of harmful effects and to maximize potential benefits, however, institutional providers need to commit to building field relationships over the “long haul,” to requiring more extensive pre-trip-preparations (see Reisch, 2011, pp. 96, 98; Cahill, 2017 , pp. 35–36; Wolfberg, 2006, p. 445; McCall and Iltis, 2014, pp. 291–295), and to ensuring that students are not “providing care outside their scope of competence” or performing “procedures they would not be permitted to do with less supervision than would be required in their home countries” ( Langowski and Iltis, 2011, pp. 74, 77; McCall and Iltis, 2014, pp. 288–291; also Melby, et al., 2016 , p. 634). None of the reported volunteer projects undertaken in Togo by Professor Piot’s students would have been possible without extensive and time-consuming stakeholder participation. Accessing local knowledge, tapping into youthful energy on both sides (Piot, 2016, p. 207), and timely local partner interventions emerge as keys to research and project success. To their credit, many of the young chapter authors of Doing Development in West Africa recognize the indispensable contributions of local partners, interpreters, and project beneficiaries. In her research on youth migration out of northern Togo, for instance, Maria Romano relies on multiple people to “map out” the village (ibid., p. 34). Kelly Andrejko’s research on the role of local medicine in an urban setting relied on interviews with 50 neighborhood residents, 50 hospital patients, and a “wide range of professionals involved in health care” (ibid., p. 85). Ideas and strategies gleaned from a local women’s micro-financing group (ibid., pp. 178–179) proved critical in Emma Smith’s micro-financing program for young adults. Equally important, community stakeholders in the South are energized and informed by contacts with engaged students. In a telling encounter, a local medical worker interrupts Alexandra Middleton’s interview to say, “Thank you for your questions. We learn from them” (ibid., p. 24; also see Hawkins, 2014, p. 561). The demonstrated value and “modest successes” (Piot, 2016, pp. 24, 210) of these small-scale, inexpensive, creative, flexible, passionately pursued, locally inspired, and community-based projects speaks directly to bilateral and international-development agencies that remain enamored with massive, capital-intensive, costly, disruptive, and top-down ventures.18 With the requisite resources and community-support built on trust from prior ground-breaking commitments by an experienced mentor, Professor Piot and the reporting students collectively articulate a convincing case for carefully engaging young volunteers in health education and development challenges and for learning, when necessary, from “false starts, missteps, detours, profound setbacks, and flat-out failure” (ibid., p. 210; also see McCall and Iltis, 2014, p. 289). However, there are important gaps in these volunteer initiatives that require attention, including • •

joint needs assessment and project planning in coordination with local communities (Sykes, 2014, p. e45; Garrett, 2007, p. 16); ownership, maintenance, and long-term-sustainability issues;

Where should we “move” from here? 217 • • •

the challenges involved in scaling up and scaling out (Rowe and Hiser, 2016, p. 327; Mader, 2014, pp. 74, 80); exit strategies (Reisch, 2011, pp. 97–98; Melby, et al., 2016, p. 635; Garrett, 2007, p. 16); appropriate and available process-, outcome-, and impact-evaluation approaches (Sykes, 2014).19

Nevertheless, the contributions of these Duke University participants are valuable, their voices are inspiring, and their informative stories leave one rooting for many more equally committed and reflective student transnational experiences in the years to come. While Duke University students are especially advantaged by the presence of the Global Health Institute and the well-funded DukeEngage program, young people on many college campuses are driven to volunteer abroad by a growing impulse – that is, the “desire to travel and learn and make a difference in the world” (Piot, 2016, p. 3, also pp. 4–5, 207; Suri, et al., 2013, p. 245; Crisp, 2016, p. 296; McCall and Iltis, 2014, p. 286). For the “movement for global health equity” to progress, many students of virtually every major and occupational interest need to become engaged in first-hand learning about the disparities that prevent people from living lives in full health and in “finding creative ways to leverage one’s own skills and interests and to work with others” to address prevailing inequities (Basilico, et al., 2013, pp. 352–353; also Illingworth, 2012, pp. 205–206; Garbern, 2009/2010, p. 43). The next section aims to operationalize this imperative in a feasible, professionally and ethically defensible, and globally impactful manner.

The Global Health and Migration Corps (GHMC) proposal This section of the concluding chapter elevates and expands the Institute of Medicine’s recommendation that the U.S. government establish a full-time and long-term Global Health Service Corps (see Mullan, Panosian, and Cuff, 2005, pp. 98–147) and Vanessa Kerry, Sara Auld, and Paul Farmer’s (2010) proposed International Health Service Corps. I also incorporate principles and approaches that are central to the more limited Global Health Corps (GHC) co-founded and chaired until recently by the late Barbara Bush.20 As set forth in the Lancet/ University of Oslo Commission on Global Governance for Health’s proposal for establishment of an Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health, the Global Health and Migration Corps (GMHC) could be created at the intergovernmental level or by non-state actors such as consortia of universities (see Ottersen, 2014, p. 659). The transnational immediate objective of the Global Health and Migration Corps proposal is to employ transnational mobility in a novel way that will effectively address contemporary shortages in skilled health-care workers that plague poor countries and underserved residents in the South and North. Both

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treatment and health-promotion needs will be addressed. The externally supported, transnationally constructed, GHMC will ensure that “additionality” is a core feature of the initiative so that its health and migration projects “do not drain talent from other local needs in both the public and private sectors” (Garrett, 2007, p. 32). Project undertakings will be undertaken consistent with a broad vision that simultaneously recognizes and addresses structural factors that underlie health and mobility inequities.21 The fundamental premise underlying creation of the GHMC is conviction that “supporters of global health equity do not need to hold official positions of power to make a significant impact” (Basilico, et al., 2013, p. 347). The newly created international organization will feature competitively selected experienced (senior and mid-career professionals) and youthful recruits22 “from different countries working side by side, very often in a country which is unfamiliar to them, and in the global public domain” (Illingworth, 2012, p. 183). Moreover, the new organization’s passionate multiprofessional and multinational23 field workers will contribute insights and innovations drawn from diverse disciplinary education and employ complementary skills in need-driven teamwork situations that span sectors and stakeholders (Frenk, et al., 2010, pp. 1951–1952; Renzaho, 2016, p. 187; McMichael, Barnett, and McMichael, 2012, p. 651). Diasporic inclusion Diaspora professionals will occupy a special place in the GHMC, where they can use expertise, insights, commitments, and transnational competence24 gained in multiple places (brain circulation) to support the health of persons living within and outside their country of origin and act as bridges for policy changes in North and South that redress structural barriers to access (see Renzaho, 2016, pp. 164, 187; Omaswa and Crisp, 2014, p. 5; Chapter 5). As noted in Chapter 5, Northern aid agencies and NGOs increasingly view diasporas as valuable sources of expertise on health and development initiatives in the South (Mavroudi and Nagel, 2016, pp. 106–107). By mobilizing migrants and the expanding numbers of their educated children who are eager to serve (Crisp, 2010, p. 13; Terrazas, 2010, p. 211), the GHMC can contribute to turning brain drain into brain gain (Renzaho, 2016, p. 188). The African Diaspora Programme’s Database of Professional Skills in the African Diaspora (Renzaho, 2016, p. 176) provides one useful resource for recruitment in this connection. Gifted and experienced diaspora professionals from a variety of fields are positioned to make important contributions that will advance glocal health and transnational understanding. In many unheralded cases, circular migrants already are active on multiple fronts in both sending and receiving places. The story of Tewolde Habtemichael, former student and research assistant of mine in Addis Ababa (1971–1972) and Missoula (1983–1985) and refugee (Box 8.1), is illustrative of the vast potential available in the diaspora for GHMC mobilization.

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Box 8.1 Tewolde Habtemicael’s circular-migration story “In 1970, when I was a student at [then] Haile Sellassie I University, I was elected as a Student Union official. At the time, many students, including myself, opposed the Imperial regime. Along with four other students, I was arrested. After one year of imprisonment, we were released and allowed to continue our education. In 1974, the Ethiopian military overthrew Emperor Haile Sellassie and took power. Twelve employees of the Ministry of Finance, including myself, opposed military rule and demanded that a people’s government be established. The military then arrested us.” Following months of imprisonment, Tewolde was released on condition that he not engage in any political activity. After some time back at the Ministry, Tewolde fled from Addis Ababa and joined the Eritrean People’s Liberation Front (EPLF)’s struggle for independence from Ethiopia. Later, he left the EPLF, crossed Sudan, entered Saudi Arabia, and flew to Rome, where he was granted official refugee status. Following admission as a refugee, he reached Washington, D.C., in March 1983. Tewolde completed the Masters of Public Administration (MPA) degree at The University of Montana in 1985 and went on to serve the states of Montana and Nevada as a highly regarded positionclassification officer until his retirement a few years ago. In late 1992, Tewolde helped arrange, and co-instruct with the author, a week-long seminar for 38 top-level officials of the Provisional Government of Eritrea, including health-ministry officers, on “capacity building for public administration.” In 1993, Tewolde was invited to deliver a series of skill-enhancing training sessions for the now-independent country’s civil servants. From November 1995 through January 1996, he joined the author on a UNICEF-initiated field-research and consultancy project on decentralization for social/health planning in rural Eritrea. As the regime of President-since-independence Isaias Afewerki became increasingly oppressive and Eritrea assembled one of the worst human-rights records in the world, Tewolde helped organize an opposition group of Eritreans in exile. He became Head of the group’s International Relations Committee in 2010. Sources: personal communication from Tewolde Habtemicael, 10 May 2018; author’s knowledge

Local sustainability Of course, even with the inclusion of diaspora professionals, the GHMC cannot be expected to fill the massive shortfall in health workers who serve underresourced communities, internally displaced persons, and migrants. One of the

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primary missions of the GHMC, therefore, will be to ensure that many more health workers are “trained locally” (Crisp, 2010, pp. 65, 206; also Frenk, et al., 2010, p. 1950) and prepared for task shifting.25 Commitment to empowering local people will constitute a core component in an early-articulated exit strategy that includes a defined time line for the phasing out of GHMC support (Melby, et al., 2016, pp. 635–636; Sheikh, et al., 2016, p. 5). Operational objectives The GHMC will endeavor to impact two operational fronts: policy (including the global health and migration dimensions of foreign policy) and health promotion26 (also see Jogerst, et al., 2015, pp. 243–245; Kickbusch, et al., 2007, p. 972). Mobility will provide the common underlying context and migration health will feature in both undertakings. The linking objective will be to advance health equity by addressing underlying structural and access obstacles.27 Special attention will be devoted to supporting the health of refugees, asylum seekers, and other survival migrants (Pottie, Hui, and Schneider, 2016, p. 301). Structural format An ideal structural form for the GHMC would merge the networking and nimbleness of an NGO with the contacts and backing of an international organization (Szabados, 2017, p. 55). The GHMC needs to be supported by a sustainable funding mechanism, such as Tim Mackey and Bryan Liang’s (2013) proposed Global Health Resource Fund (GHRF), which would be coordinated by a new combined WHO/World Bank special agency. To ensure financial support, the GHRF would use a fee-assessment system under which prosperous nations would commit to the largest annual contributions (Mackey and Liang, 2013). The GMHC’s governing board would include representatives of ministries of health from Southern countries facing shortages of health-care workers, healthcare associations, NGOs with migrant-health and peace-building missions, philanthropic bodies, diaspora associations, multilateral organizations, bilateral donors, and private firms affiliated with the global-health-care industry. These stakeholders would be responsible for hiring the director and other top GHMC officials, for developing general project guidelines,28 for ensuring “ethical and fair use of the funds,” and for maintaining accountability (ibid.). Five operational building blocks should serve as structural pillars for the proposed GHMC:29 • •

specific project and funding priorities are responsive to needs identified from below rather than from abroad; implementing units are organized and administered in a manner that encourages managers to innovate and to build cumulative operational experience into the project cycle;

Where should we “move” from here? 221 • •

•

financial operations and reporting adhere to professional standards of accountability; eligibility criteria, application procedures, audits, and evaluation standards are transparent and readily understood across stakeholders (Mackey and Liang, 2013), and compliance is relatively uncomplicated rigorous project evaluations conducted by an independent group emphasize outcomes and impacts (See Koehn and Uitto, 2017).

GHMC headquarters (also see Koehn, 1999, pp. 44–46) will establish operating policies and identify specific project guidelines. Headquarters also will function as a fund-raising and distributing body. Headquarters staff will not allocate awards or implement projects, however. Regional GHMC offices will be organized in five divisions: administrative support, project awards, project execution, funds management, and monitoring and evaluation. Project-award divisions will be responsible for developing appropriate selection criteria,30 assisting local applicants prepare viable project proposals, assessing the merits of submitted proposals, and recommending approval, revision, or rejection (see Koehn, 1999, pp. 46–52). Project-execution divisions implement GHMC-staffed initiatives and support projects awarded to external petitioners. Projects and participants GHMC’s externally supported and internally implemented projects will draw upon lessons articulated by Charles Piot (2016, p. 210) in reflecting upon his students’ modest successes in Togo: “Aim small .  .  . and focus on the managerial . . . as much as the technical.” They will also build upon insights from successful Partners In Health initiatives, including “working in public-health systems” and incorporating ancillary services (including transportation, financial security, education and TC training, housing, clean water, sanitation) that help to overcome structural barriers to health-care access and wellness promotion (Suri, et al., 2013, p. 277). Selected projects primarily will be drawn from among those where collaborating placement organizations and local communities (Melby, et al., 2016, p. 636) identify critical skill gaps that need to be filled.31 To maximize prospects for sustainability, GHMC projects should be designed to include “early engagement of [a wide variety of] stakeholders, explicit plans for scale up, strategies for influencing policies, [an exit strategy, and rigorous] quality assessments” (Bates, et al., 2011).32 As Francis Omaswa and Nigel Crisp (2014, p. 4) note, “good health starts with, and is created by, individuals, their families, and communities and is supported, where necessary, by the skills, knowledge, and technology of the professionals; not the other way around” (also see Were, 2014, pp. 114–115). Regional project-execution divisions possess the most crucial set of line responsibilities and require the largest staff (see Koehn, 1999, pp. 46–52). Personal experience leads me to agree with Dr. Gilbert M. Burnham, Co-director

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of the Center for Refugee and Disaster Response at Johns Hopkins Bloomberg School of Public Health, that transnational service is optimized by multi-year commitments. Based on his 15 years of work in Africa, Dr. Burnham concludes, The real impact is made by people who are able to stay in a place for years on end. In my own experience, it took a year to really understand what was going on in a cultural and social context. (cited in Wolfberg, 2006, p. 444; also see Garbern, 2009/2010, p. 42)33 Therefore, the GHMC will recruit, and employ on a salaried basis, professionals who are committed to rotating long-term placements on a transnational basis and are dedicated to increasing global health equity (also see Kerry, Auld, and Farmer, 2010, p. 1200). In addition to doctors, the GHMC would include “nurses, physical therapists, and experts in technology and bioengineering who could help to address the diverse public health needs in resource-poor settings” (Kerry, Auld, and Farmer, 2010, p. 1200) as well as “public health experts, development practitioners, engineers, anthropologists, and others” (Melby, et al., 2016, p. 63534). In contrast to most short-term volunteer-service initiatives, personnel assigned to the GHMC’s regional project-execution divisions will be positioned to address the “primary sources” of global and migrant health-care problems – including “poverty and overstretched health care infrastructure” (Sykes, 2014, p. e38), armed conflict, migration trauma – and to identify and appreciate reverse innovations (Melby, et al., 2016, pp. 635–636; Crisp, 2010, p. 14). The TC-training foundation Transnational-competence education provides an essential undergirding foundation for the Global Health and Migration Corps proposal elaborated in this section. By 2006, 27 percent of graduating medical students in the United States had elected to participate in an overseas professional experience as part of their academic preparation (Drain, et al., 2007, p. 227). However, as discovered by the Lancet Commission on Education of Health Professionals for the 21st Century, many of these experiences remain to be integrated into a comprehensive, transformative, transnational-skill-based curriculum that incorporates advocacy training (Frenk, et al., 2010, pp. 1923, 1933, 1951). For maximum impact, GHMC pre-departure and on-site training would be delivered in multiple physical locations, be infused with challenges set in transnational contexts, and integrate learning experiences under mentors from multiple (including resource-poor) countries and diverse professional backgrounds (also see Harden, 2006, pp. S25–S27; Cole, et al., 2013, p. 157). The foundational TC-curriculum elaborated in Chapter 4 would provide valuable preparation for professional assignments with the Global Health and Migration Corps. Competency lessons drawn from U.S. student experiences in West Africa also would be an integral part of GHMC pre-departure preparation.

Where should we “move” from here? 223 Examples based on extensive experience from Charles Piot’s Doing Development in West Africa (Piot, 2016, p. 10; also p. 207) include remaining “open minded and flexible, always on the lookout for surprises”; learning to improvise and innovate along the way (creative TC); and adopting “an attitude of humility toward the local and assum[ing] that local knowledge (about crops, soils, markets, health) will trump outside knowledge most of the time – that one’s first instinct should be to find out from villagers how and why they do what they do” (emotional TC). Further inspiration would be drawn from the experience of the Center for International Humanitarian Cooperation’s intensive International Diploma in Humanitarian Assistance (IDHA) training course (see testimonials in Cahill, 2017, pp. 52–119). TC training, like the IDHA approach, would enable participants “to see and touch what is essential” (Ward and Pucci, 2017, p. 119). Also incorporated in GHMC training programs would be raised awareness of global health disparities and inequities; how social determinants influence health and migration outcomes; the connection of climate-change abatement and adaptation to health and migration (McMichael, 2013, p. 1342); the value of health promotion; and how multi-sector policies and practices “can exacerbate or ameliorate health inequities” (WHO Commission on Social Determinants of Health, 2008, p. 188; also Jogerst, et al., 2015, pp. 243–245; Melby, et al., 2016, p. 636) and drive mobility decisions and outcomes (analytic competence). Recruits will be prepared for work in grueling and emotionally unsettling contexts that involve “preventable suffering and death, global inequities of disturbing proportions, and . . . problems [that] lack simple solutions” (Suri, et al., 2013, p. 246) (emotional TC). Upon invitation to serve side by side with local workers, GHMC personnel will be able to formulate an exit strategy that will guide external involvement in ways that avert dependency (functional TC). At the same time, vital upstream actions would be emphasized across the health and migration curriculum, including strategies that aim to ameliorate poverty (Kerry, Auld, and Farmer, 2010, p. 1200) and to facilitate the avoidance and reduction of armed conflict and civilian casualties. Recruits will be prepared and inspired to “practice social justice”35 on a daily basis (functional TC). In the upstream-action connection, TC-trained GHMC practitioners would be encouraged to link with Atlantic Fellows for Health Equity in South Africa and Southeast Asia, with GHC fellows and alums in Rwanda, Uganda, Malawi, Zambia, and northeastern United States, and with other reinforcing migration, international-development, and health-protecting activities such as the Medical Education Partnership Initiative (MEPI) (Melby, et al., 2016, pp. 635, 637). Along with imparting skills with application to conflict-prevention and conflict-reduction situations (Arya, Melf, and Buhmann, 2008, p. 301),36 GHMC training would include preparation for peace-through-health advocacy work (see Buhmann and Pinto, 2008, pp. 293–296). Medical images and explanations that resonate with GHMC personnel who deal with armed-conflict-induced migration can be compelling as part of a “preventive-diplomacy” policy approach that utilizes the methodology and terminology of public health. For instance,

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Where should we “move” from here? there are contagious effects in conflicts that may cause political paralysis, and the hemorrhaging of societal understanding leading to mental scars, post traumatic psychological syndromes, physical deformities, amputations, . . . sexual assaults and the escalation to epidemic levels of uncontrolled feverish fighting. (Cahill, 2017, p. 158; also pp. 159–170)

Kevin Cahill further elaborates this upstream connection in the compelling terms captured in Box 8.2.

Box 8.2 Upstream armed-conflict epidemiology Preventive diplomacy emphasizes earlier diagnoses and new kinds of therapy. Underlying causes have to be attacked sooner rather than later before they become fulminating infections that rage beyond rational control or political containment. ### In preventive medicine one begins by searching for fundamental causes, for the etiology of a disease, and for techniques that can interpret transmission before serious signs and symptoms become obvious and irreversible damage occurs.  .  . . When deaths do occur, scrupulous postmortem analyses are customary, so that the errors of the past become the building blocks for a better approach to the future. One should . . . be able to adapt this approach to the epidemiology of conflict. Source: Cahill (2017, pp. 161–164)

Matthew Basilico and colleagues (2013, pp. 348–349) suggest two additional helpful preparatory skills to build into GHMC training. First: “listen carefully to others, especially those who disagree with you. Everyone has a valuable perspective worth considering as you seek to improve your own platform and strategy” (communicative competence). Second: stress the value of advocacy and building a broad-based, multidisciplinary coalition of “thoughtful and engaged” supporters who are committed to advancing global health equity. Prepping for this purpose includes developing courage and confidence to advocate “for migrant populations that face discrimination and withdrawal of basic health care services” (Pottie and Gruner, 2016, p. 339). Effective health care has “always been about teamwork”37 and “the bringing together of different perspectives and skills to a common purpose” (Frenk, et al., 2010, p. 1943; Crisp, 2010, p. 203; also Jogerst, et al., 2015, p. 245) (functional TC).

Where should we “move” from here? 225

Outcome and impact evaluations Wide adoption of the principal components of a strategy for moving forward articulated in this chapter – TC education, symmetrical partnerships, and GHMC initiatives – depends upon collaborative and credible evaluations of outcomes and impacts. Regrettably, key global health and migrant-health assessments remain misdirected and of limited utility. Public-health-service organizations “do not regularly include” evaluation research as part of their on-the-ground operations (Sykes, 2014, p. e40) and the performance of the multitudes of health and migrant volunteers who serve a plethora of large and small organizations typically is not systematically evaluated (Wolfberg, 2006, pp. 444–445; Sykes, 2014, pp. e45–e46; Maki, et al., 2008). Cost-effectiveness analysis “can lead to unintended, and in some cases perverse, consequences” and metrics that exclusively measure health-centered variables “can obscure the broader social determinants of health, not to mention the effects of large-scale social change on health outcomes” (Becker, et al., 2013, pp. 232, 234). In the absence of “major improvements in data collection, processing, access, analysis, and application, desired improvements in global health will inevitably be retarded” (McCracken and Phillips, 2017, p. 32). In order that critical lessons regarding global health and migration are learned from and improved upon, quality outcome and impact evaluations should be “universally included” in education, partnership, and project activities (Sykes, 2014, pp. e45–e46). This section presents suggested approaches for advancing the evaluation of TC education and training, transnational partnerships, and GHMC initiatives. Evaluation is carried out for multiple purposes, including generating new insights, action-pathway identification, policy and program improvement; shared and continuous institutional and stakeholder learning (Gibson, 2005, p. 155); and accountability for results achieved and resources used. Monitoring involves the frequent and ongoing tracking of changes in inputs, activities, outputs, and preliminary outcomes in order to inform program implementation and improvement (Zint, 2011, p. 332). Process evaluations aim to determine the extent to which participants implemented planned activities as intended. Summative evaluations typically draw on monitoring and process insights and occur following or near the end of interventions to determine the extent to which project, program, or policy features (as opposed to external factors) contributed to changes in outcomes and impacts (Zint, 2011, pp. 332–337). Meaningful evaluation involves a rigorous, systematic, and evidence-based process of collecting, analyzing, and interpreting information to answer specific questions. Common steps in the evaluation process involve (1) the identification of questions, relevant criteria, and target audiences; (2) developing a research design that will guide the collection and analysis of collected data; (3) analyzing and disseminating results; and (4) promoting the use of findings (ibid. p. 332). Useful evaluations provide assessments of what works and why in what context, highlight intended and unintended benefits and harms (Sykes, 2014, p. e40), and provide strategic, future-oriented lessons to guide decision makers and inform

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stakeholders. Although evaluation involves an important accountability dimension for results (not)achieved and resources used, it is most valuable when also utilized by stakeholders for program improvement (or termination) and in connection with learning lessons for future application. Comprehensive evaluations need to cover inputs, outputs, processes, outcomes, and impacts. An output is a “tangible product (including services) of an intervention that is directly attributable to the initiative” (UNDP, 2011). Outputs relate to the extent (amount, volume) of completion of the goals that actors set for themselves (Poister, Aristigueta, and Hall, 2015, p. 58) rather than the conduct (process) of activities. Outputs are the type of results over which program and project managers can exert the most influence. However, the generation of outputs provides “no guarantee that outcomes will result” (Poister, Aristigueta, and Hall, 2015, p. 58) and exclusive reliance on output evaluations, the “default approach,” “precludes the ability to measure efficacy of interventions performed” (Sykes, 2014, p. e44). An outcome is the “actual or intended changes in  . . . conditions that an intervention seeks to support” (UNDP, 2011; emphasis added). Global health and migration conditions include policies, institutional capacities, and human capabilities. Impact involves major improvements in human well-being. Who (and what) is directly and indirectly better off and worse off (Thabrew, Wiek, and Ries, 2009, p. 71)? Under what circumstances, and why? Impact evaluations should encompass individual (private) and social (collective) benefits and losses. Relevant and helpful assessments are of practical utility, ongoing, and trigger remedial actions (see Koehn and Uitto, 2017). Three types of outcome and impact evaluations are of particular interest under the framework for analyzing transnational mobility and global health presented in this chapter. The discussions that follow focus on suggested approaches to transnational-competency evaluations, partnership evaluations, and project evaluations. All three aspects of evaluation would prove useful in continuous assessment of the proposed GHMC. Transnational-competency evaluations Rather than relying exclusively on technical knowledge or on numerical output indicators such as the attainment of qualifying credentials, human-capabilities evaluation emphasizes comprehensive outcomes (Frenk, et al., 2010, pp. 1949, 1952) and performance impacts. A useful approach to evaluating TC training and education for health and migration assignments initially centers on preparatory training and individual human-capabilities enhancement. Preparatory learning should be skill-based and informed by valuable experience. Evaluations begin by exploring the process utilized. Did a broad range of stakeholders, along with transnationally competent educators and experienced practitioners, participate in developing training objectives and approaches? Among other advantages, external-stakeholder input provides “a means of validating the relevance of competencies and ensuring key domains are not neglected” (Gruppen, Mangrulkar, and Kolars, 2012, p. 45).

Where should we “move” from here? 227 Other process-focused inquiries shed further light on the outcome of preparatory learning. Was pre-departure training delivered in multiple physical locations and infused with challenges set in transnational contexts? Did TC training  include relevant field-learning experiences under mentors from multiple (including resource-poor) countries and professional backgrounds? To what extent did instructor assessments of student TC development address transnational health and mobility insights and contributions? Evaluating the content of training programs also is important. Did transdisciplinary integration occur? Did assigned resources, instruction, and mentoring emphasize upstream influences and social determinants? Did trainers emphasize the value of health promotion and preventative actions? Did training include preparation for peace-through-health advocacy work? The crux of transnational-competency evaluation is outcome- and impactbased. Both practitioner-oriented and program-oriented training (see Jogerst, et al., 2015, p. 242) require review. Among practitioners, evaluators distinguish levels of skill attainment: learn, practice, and demonstrate (Desha and Hargroves, 2014, p. 143). Eliciting the perceptions of poor and marginalized populations should be incorporated as a core component of practitioner TC-competency evaluations. Multisource feedback, especially from stakeholders, promotes comprehensive-skill assessment and enables the graduating professional to grasp “both his or her personal strengths and areas in need of development” (Shuman, Besterfield-Sacre, and McGourty, 2005, p. 50). Program-outcome evaluations are concerned with individual human capabilities; they explore the presence or absence of growth across all five TC dimensions (see Koehn and Uitto, 2017, pp. 139–143). The outcome emphasis is on evidence of “behavioral additionality” (Ravetz, 2007, p. 83). Competencies developed or diminished after graduation or completion of a specific training program should be documented over the long term through follow-up studies. A 360-degree evaluation approach “is widely recognized as a quality improvement method . . . able to assess multiple aspects of competence” (Maki, et al., 2008; also Koehn, 2005b, 2006b). Individual-learning outcomes also can be measured usefully in relation to asset building as reflected in “health, family life and social capital” (Schuller, Hammond, and Preston, 2004, p. 12). How did TC education and experiential learning impact the life trajectory of participants (Sykes, 2014, p. e44)? Impact evaluations center on demonstrated trainee contributions to areas of global health and migration policy and practice. Graduates are expected to demonstrate individual and transdisciplinary-team achievements across all five transnational-competency domains and when confronted by varying health and migration circumstances.38 Evaluators are interested in whether practitioners working in transnational health and migration contexts serve as change agents – i.e., “actually do exercise their professional capabilities in ways that further social transformation” (Walker, et al., 2009, p. 568; also Frenk, et al., 2010, p. 1952) – rather than perpetuate or exacerbate inequities (Schuller and Desjardins, 2007, pp. 59, 114). Have individual-learning assets been used to generate “social outcomes that benefit others and future generations” (McMahon, 2009,

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p. 5, 38)? Have TC-prepared graduates demonstrated sound ethical reasoning and responsibility (Cole, et al., 2013, p. 156)? What impact shortfalls can be identified? To facilitate meaningful impact evaluation, evaluators establish observable and measurable standards of activity and task performance that are representative of desired transnational health and mobility competencies along with explicit criteria for measuring the extent to which objectives are attained. Collecting “most significant change stories” (Brundiers, et al., 2014, pp. 220–221) and criticalincident debriefings (Cole, et al., 2013, p. 157) can offer particularly revealing means of identifying impacts. For impact evaluations, the linked technical and interpersonal performance of practitioners needs to be evaluated periodically over the long term from multiple perspectives by socio-culturally diverse observers, collaborators, employers, service recipients, and community members. Long-term assessments coupled with continuing TC-based education promotes “lifelong global health learning” (Jogerst, et al., 2015, p. 246). Training process and content variables next can be examined in connection with competency outcomes and impacts. There is considerable utility in the application of learning from such linked inquiries in the preparation and delivery of future training approaches. Three illustrative queries are offered here: In what ways did supervised field work contribute to TC enhancement? Which training lessons led to improvements in emotional competence? Which training approaches are most frequently associated with trainee contributions to improved health education and practices among refugees and irregular migrants? Partnership evaluations Partnering potentially enables organizations worldwide to mobilize the transdisciplinary expertise of professionals who possess the capability to navigate and connect the global and the local, and to apply knowledge from diverse sources for the benefit of individual migrant and population health. Partnership evaluations should address process, outcomes, and impacts. However, partnership evaluators have lagged behind in determining “how collaboration is working (or not), and how shared responsibility is to be understood and measured” (Rist, 2013, p. 260). With regard to transnational higher-education partnerships involving nonuniversity stakeholders, Robert Marten and Jan Witte (2008, p. 21) found that “few foundations invest in monitoring and evaluation, and even fewer conduct thorough impact evaluations.” Instead, most partnership evaluations concentrate on immediate and readily quantifiable inputs and outputs. Symmetrical processes Evaluations of transnational partnerships need to consider processes and pathways. Evaluating the life course of a THEP can be distinguished by phases. Partnership and project design and planning are featured during the inception phase. The

Where should we “move” from here? 229 management or implementation phase is followed by the closing or sustainability interval. The first evaluative criteria to be applied in assessing health and migration partnership designs should specifically consider whether or not the reasons advanced for adopting the transnationally collaborative approach outweighed the arguments in favor of unilateral implementation (Catley-Carlson, 2004, p. 22). Process evaluations specifically explore the presence or absence of symmetry in North-South institutional relationships. Equitable inclusion and the pursuit of mutually beneficial relations feature here. Did partners agree at the start on the relevance of the problem, on research objectives, and on methods of inquiry (Brundiers, et al., 2014, p. 203)? Did each partner have a clear and accurate understanding of the contributions that each collaborator would bring to the enterprise as whole (Catley-Carlson, 2004, p. 21)? Were initial expectations on the part of one of more partners unrealistically high (Samoff and Carrol, 2004, p. 130)? The design of partnership governance also requires evaluation. Did the partners jointly establish a formal governance structure (Afsana, et al., 2009, p. 15)? How inclusive, balanced, and transparent (Stone, 2004, p. 157) was the original design and any subsequent iterations? Did key administrators at all partner institutions endorse the initiative? Did partners jointly negotiate a charter-like agreement that set forth consensus principles that would guide the collaboration (Sanchez and Lopez, 2013, p. 133)? Did participants agree on strategies for managing and minimizing conflicts that might arise over the course of the THEP (Larkan, et al., 2016, p. 23)? Did managers resist imposing burdensome administrative procedures so that all partners were free to focus on the principal objectives of the partnership (Catley-Carlson, 2004, p. 26)? THEPs devoted to global health and migration evaluate relationship dynamics as well as the partnership design. Were the champions of collaboration credible and highly regarded at all partner universities? Did participants, including senior officers, across the relevant units of partner institutions and external entities enthusiastically engage in project activities and take initiatives or “exhibit a fatalistic orientation to collaborative working” (Walsh and Kahn, 2010, p. 45)? In the interest of promoting and sustaining THEPs devoted to global health and migration, additional management issues also require comprehensive attention during the evaluation process. Did partnership members agree on a plan for involving relevant stakeholders in project undertakings (Afsana, et al., 2009, p. 17)? To what extent were community members involved in designing study components, project implementation, results sharing, joint analysis of collected data (Hussein and Upshur, 2013, pp. 106, 108; Walsh and Kahn, 2010, p. 67), and policy change? Did partners build symmetrical and sustained linkages with other stakeholders (Jones, Bailey, and Lyytikäinen, 2007, p. 10)? Budgeting constitutes a key dimension of THEP management. Did senior managers allocate adequate staffing, resources, and rewards? Were program budgets transparent and shared? To what extent were budgets equitably distributed among transnational partners according to agreed-upon responsibilities? How

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deeply was control over funds devolved (Jones, Bailey, and Lyytikäinen, 2007, p. 21)? To what extent is each partner satisfied with the allocation of resources and budgetary decision making (Afsana, et al., 2009, p. 19)? Mutual trust and respect is a defining aspect of effective North-South THEP management (see, for instance, Jones, Bailey, and Lyytikäinen, 2007, p. 8). Trust has interpersonal, inter-group, and inter-institutional dimensions (Schuller and Desjardins, 2007, p. 70). Has partnership management been characterized by deep trust among all partners and by effective conflict management (Stern, 2004, p. 32)? Specifically, were disagreements and incidents that might have derailed the partnership openly discussed and resolved in ways that strengthened the THEP (Boydell and Rugkasa, 2007, p. 224)? Major perceptual differences on levels of trust among partners suggest problems associated with unbalanced management. Addressing means as well as ends is necessary in holistic partnership evaluations. Research and evaluation findings suggest that a sense of joint ownership among partnered universities and communities is likely to be associated with favorable partner and partnership-sustaining outcomes (Fukuda-Parr, Lopes, and Malik, 2002, p. 14). Missing from evaluations that are reduced to financial calculations are such important considerations as participant willingness to take on risk and pursue innovative approaches. Did participants “welcome serendipity and unexpected developments” (Austin and Foxcroft, 2011, p. 130)? The symmetrical-management process also involves collaborative monitoring and evaluation. Were stakeholders involved in monitoring progress and evaluating outcomes (Stern, 2004, p. 31)? Did the partners conduct agreed-upon monitoring and evaluation exercises at regular intervals (Wanni, Hinz, and Day, 2010, p. 58)? To what extent were project components, strategies, and symmetrical arrangements refined and improved (Wanni, Hinz, and Day, 2010, p. 58) based upon feedback from and reflection regarding outcomes, impacts, and changes in priorities by all partners (Stern, 2004, p. 38)? Have university governing bodies, donors, and community constituencies received progress reports (Stern, 2004, p. 38)? Do external stakeholders remain supportive of the partnership? Finally, did the partners formulate an exit strategy? Did they agree in advance on, and follow-through with, a “closing plan” (Afsana, et al., 2009, p. 18; Larkan, et al., 2016, p. 20)? Partnership outcomes In an outcome typology employed to evaluate transnational-health partnerships, Edwards and colleagues (2015, p. 3) merge organizational capacity and individual capabilities. Partnerships that emphasize both infrastructure strengthening and generic skills that are transferable across a number of tasks have the highest probability of being associated with desired long-term outcomes (Edwards, et al., 2015, pp. 51–52). In particular, experience in handling budget decisions advances sustainable institutional capacity among Southern partners (see, for instance, Muir, et al., 2016, p. 2). Are continuous skill-updating opportunities provided? Did partners enhance the capabilities of local researchers and public-health policy

Where should we “move” from here? 231 makers through training and mentoring (Hussein and Upshur, 2013, pp. 106, 114)? How has commitment to the training of trainers been demonstrated? Although THEPs might primarily focus on improving institutional capacity, enhancing human capabilities, strengthening networks of professional communication, and supporting public-health efforts in low-income countries, thoughtful analysts have observed that they must simultaneously build capacity in the North as well as in the South (Bradley, 2008; Habermann, 2008). What did Northern partners learn from their Southern colleagues and from the migrants and communities they worked with (Murphy, et al., 2013, p. 127)? A study of 65 articles published in English between 1990 and 2010 is particularly encompassing and detailed in terms of “reverse innovation.” The authors identify multiple health-care lessons in each of WHO’s six “building blocks of health systems” based on initiatives and experiences in poor countries that rich countries have benefitted from through transnational partnering. For instance, a U.S-based AIDS program seeking to increase patient follow-up treatment found inspiration from a community- and patient-centered project undertaken in Zambia as part of a University of Alabama at Birmingham partnership initiative (Syed, et al., 2012). The investigators conclude by identifying ten areas of health care where Northern countries have the most to learn from Southern practice: providing services to remote areas, skills substitution, decentralization of management, creative problem solving, education for communicable-disease control, innovation in mobile phone use, low-tech simulation training, local-product manufacture, health financing, and social entrepreneurship (ibid., 2012). Partnership impacts The core impact of a transnational partnership devoted to advancing global health can be understood as “the contributions that it makes in terms of significant and lasting changes in the well-being of populations in the South” (Obamba, Mwema, and Riechi, 2011, p. 2). To date, THEPs of all types lack standardized impact measurement (Muir, et. al., 2016, pp. 2, 31; Koehn and Uitto, 2017). Measuring the impact of transnational health-tourism procedures on Northern patients and Southern populations, including those undertaken through collaborative NorthSouth ventures (see Chapter 1), is especially problematic (Crone, 2008, p. 120). In many transnationally linked fields of study, local discovery provides the key to the generation of valuable community and global innovations (Crossley and Holmes, 2001, p. 396). To yield meaningful insights, therefore, THEP evaluations need to be broadened beyond externally imposed quantitative measures and global metrics (Sanchez and Lopez, 2013, p. 133). A variety of forms of triangulation, including methodological, data, investigator, time, space, person, and theory triangulation, can be employed to increase confidence in partnership evaluations (Green and Tones, 2010, p. 503; Collins, 2014, pp. 947–948). Evaluations that concentrate on identifying contributions toward impact objectives are particularly well suited for partnership initiatives (Hummelbrunner, 2012, p. 265). Catalytic impacts on transformation processes and rule-making

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systems shaping health and migration merit exploration in this connection. What evidence is there of contributions by THEP undertakings to policy change and societal transformations (Sanchez and Lopez, 2013, p. 133)? Further, THEP interventions can contribute in unintended ways to health and global-health impacts. Tracer studies illuminate the chain of impact by university graduates and community trainees (Jones, Bailey, and Lyytikäinen, 2007, p. 18). What intended and unintended impact contributions are revealed by the chain of impact? Meaningful partnership evaluations also involve determinations of sustainable external impacts. THEP impacts rest in large measure on stakeholder followthrough. To what extent have various stakeholders (academics, government personnel, NGO and community members, donors) received and acted upon partnership-research findings related to migration and to global health (Afsana, et al., 2009, p. 21)? GHMC initiative evaluations Evaluation of GHMC initiatives also needs to focus on process, outcomes, and project impacts. Project contributions can be evaluated in terms of impact on the GHMC participant, local health-care providers, patients, the target community, other stakeholders, migration policy, and, ultimately, on global health. Ethnographic inquiries uncover grassroots outcomes and impacts, including stakeholder empowerment (Powell, Molander, and Celebicic, 2012, p. 219). Since behavior and policy change are multidimensional, impact evaluations often focus on catalytic influences. Process and outcomes Participatory evaluation engages the stakeholders of a GHMC-sponsored or implemented program or project. Stakeholder involvement in project evaluations carries the benefit of enriched triangulated perspectives on local outcomes (see Becker, et al., 2013, p. 242; Oakley, 1991, pp. 263–266). In particular, external evaluators appreciate the value of participant observations and treat the process as a mutual-learning experience (Joel Samoff, cited in Crossley, et al., 2005, p. 106; Jones, Bailey, and Lyytikäinen, 2007, p. 10) that simultaneously taps stakeholder perspectives on the wisdom of revising evaluation criteria as projects evolve (Bates, et al., 2011). In ethnographic field work in China, Elanah Uretsky found “locally generated responses” to be more effective than technical support in “changing the behaviors that place people at risk for HIV infection.” A key GHMC-project outcome to evaluate, therefore, is the extent to which imparting “critical abilities to develop programs that can furnish a culturally compelling reason to work toward prevention” (Uretsky, 2016, p. 181) has been attained. Impacts Rather than concentrate on input funding or easily measurable outputs, values-based-impact evaluations emphasize achievements that matter most to

Where should we “move” from here? 233 beneficiaries (see Hoover, 2015; Crisp, 2010, p. 16). For Amartya Sen (e.g., 1999), life improvements are about expanding a person’s functionings and capabilities – things they are able to “do” and “be” – and their set of available options. In what ways did the GHMC project enhance individual and community functioning? Is there evidence that the GHMC project contributed to advances or setbacks in human well-being? Did work with migrants relieve distress, demoralization, and stigma (Becker, et al., 2013, p. 242)? When projects involve treatment, early and late patient-impact evaluations include compliance, survival, and recovery rates, restoration of function, satisfaction, and quality-of-life assessments (Sykes, 2014, pp. e43, e45). Impact evaluations aim to generate “a clearer understanding of the influence of a development project . . . on people’s lives” (Crossley, et al., 2005, p. 38) and insights regarding ways to reduce vulnerability among men, women, and children on the move or threatened by climate displacement (McMichael, Barnett, and McMichael, 2012, p. 652).39 The impact of projects on underlying determinants requires systematic attention. Specifically, did the project and connected policies facilitate or jeopardize the availability, accessibility, and acceptability of key health-protection and migrant-well-being services and conditions (see Labonte, 2013, p. 99; Melby, et al., 2016, p. 636)? On most global health and migration projects, social impacts – including the creation of employment opportunities (Tarabini, 2010, p. 209), the reduction of poverty and inequality (Singh, 2007, p. 76; Bailey, 2010, p. 44), and contributions to the strengthening of civil society (Schuller and Desjardins, 2007, pp. 68, 88; McMahon, 2009, p. 34) – must be addressed. How have GHMC and/or other personnel exercised professional capabilities and transnational competence in ways that furthered public health? Is there evidence that the GHMC project contributed to reductions or increases in social and economic inequality? Impact evaluations often are best served by targeting specific aspects of a publicengagement project that are perceived to be successful and unsuccessful and, then, identifying “why” (Smith, 2000, p. 217). To what extent did the GHMC initiative enhance practice at one or more of the following levels of activity: improved individual-practitioner decision making when confronted by practical and contextual challenges; improved group-level collaboration on a shared challenge; improved community-level response to a specific small-scale health or migration challenge; and improved national and/or transnational response to a challenge with cross-boundary effects? In addition, GHMC project evaluations should allow for serendipity of outcomes and catalytic impacts. Evaluators need to be open to looking beyond the individual intervention, to see the program or project in its broader context, and to be alert to unexpected impacts and spin-offs, both positive and negative. Sustainability prospects Prospects for sustainability are enhanced when projects incorporate evolving national and subnational priorities. What evidence is there that policy makers have recognized the contributions and population-health benefits of specific

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GHMC approaches and practices? The conversion of research findings and project interventions into policies and practices that support community-embraced preventive health and peace-building processes is a compelling indication of sustainable impact. Is there evidence of improvements in public service to local and migrant communities that can be attributed, at least in part, to a GHMC project? Is there evidence that the GHMC-initiated project specifically contributed to improvements or reductions in public-health service to local communities and migrants? How often are the GHMC’s partners called upon by in-country agencies for policy advice, consultancies (Bates, et al., 2011), research services, and training programs? To what extent were any shortcomings identified and reported by evaluators rectified by participants? Have stakeholders permanently adopted GHMCproject innovations (Stockmann, 2012, p. 8)? Is there evidence of increases in sustainable-health innovations that can be plausibly attributed to the GHMC intervention? Do project benefits (intended and unintended, tangible and intangible, wanted and unwanted) continue to outweigh the costs and difficulties of interacting and coordinating for participants? Have local participants taken over responsibility for making key project decisions, adapting, and innovating (Bates, et al., 2011)? Is there evidence of community-based ownership that has increased the likelihood of self-generated stakeholder-health and migrant-dedicated initiatives and replications? Are additional players (NGOs, governments, for-profit firms, community members) committed to maintaining key GHMC project activities? Has long-term funding for core services been secured (Bates, et al., 2011)?

Prospects for increased transnational-health equity in an age of mobility Advancing health equity is positioned as “one of the ranking human rights challenge [sic] of our times” (Farmer, et al., 2013, p. 303; also Frenk, et al., 2010, pp. 1951–1952). The guiding vision for transnational-health equity encompasses all people and embraces our interdependence. The requisite vision embodies the human-rights discourse related to universal standards for health and well-being along with social and political determinants (see Suri, et al., 2013, pp. 270–271). It addresses the causes and consequences of population mobility (see Martin, et al., 2017). It pursues mitigation of the structural factors responsible for perpetuating unnecessary and unjust differences that exacerbate health disparities among marginalized populations (Stewart, 2017, p. 117). It recognizes border porosity and facilitates circular migration (Penttinen and Kynsilehto, 2017, p. 148). It employs mobile providers to rectify gaps attributable in part to other provider movements. It includes a “shared commitment that each and every country must have a safe minimum level of health workers to meet the needs of its population” (Crisp, 2010, p. 79). The upstream, midstream, and downstream obstacles to advancing health equity are pervasive and powerful; they include such daunting challenges as poverty, persecution, armed conflict, climatic change, migrant vulnerability, shortages

Where should we “move” from here? 235 of health workers, and Southern resource gaps. To an increasing extent, the pursuit of global health and health equity is tied to mobility behavior and impacts. The consequential management of the health challenges associated with mobility considered in this book “will require an integration of national and global health initiatives for both infectious and non-infectious disease conditions” (Gushulak and MacPherson, 2006). Future health-promotion gains will arise from mutually beneficial partnering and collaborating among rich and poor that provides for shared learning (Crisp, 2010, p. 15; Kanth, Gleicher, and Guo, 2013, p. 289). A promising transformative global health initiative also features • •

• •

the creation of global social capital (Illingworth, 2012, pp. 180–183, 193, 201; Penttinen and Kynsilehto, 2017, p. 157); the recognition, mobilization, and expression of cross-boundary solidarity (Upshur, Benatar, and Pinto, 2013, pp. 31–32) and responsibility sharing (Martin, et al., 2017); the exercise of transnational competence (Chapter 4); and enhanced ability to “act effectively in the political arena” (Kickbusch, 2015; also Davies, 2010, pp. 189–190).

Glocally impactful action depends, in large measure, on the advocacy dimension of transnational-functional competence (see, for instance, Basilico, et al., 2013, pp. 340–347). Predictive, preventative, proactive, and ethically infused40 initiatives are called for (Stewart, 2017, p. 119; Toole, 2006, p. 202). In this connection, weaknesses in global governance need to be rectified so that states are held accountable for obligations to population health under international conventions and strong institutions are established that “ensure that health is taken into account in the development of migration policy” (Ottersen, et al., 2014, p. 651). Establishment of a Commission on Twenty-First Century Global Health and Mobility Challenges, “with very atypical membership” (Kickbusch, 2017), would constitute a compelling step toward filling the prevailing governance space. In the interim, WHO, under the leadership of Director General Tedros Ghebreyesus, can begin to “change the trajectory” of global health and migration policy by incorporating as fundamental considerations the Sustainable Development Goals and climate-change issues (ibid.; also Chapters 5 and 7). Finally, it is essential that equity considerations and social determinants be integral components of health-impact and migration-impact assessments. To enhance such undertakings, the capacity to conduct meaningful cross-sectoral, health-equity-impact evaluations must be developed and expanded.41 The proposed Global Health and Migration Corps could assist in this urgent endeavor.

Notes 1 See the “fatal flow of expertise” evidence presented in Chapter 5. 2 In 2016, more than 50,000 Cuban health workers (with half being physicians) served in health missions in 68 countries (Crisp, 2016, p. 148; also see Chapter 5). Current

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South-South health collaborations include institutional-capacity building and futureoriented agendas (Buss and Faid, 2013, pp. 310–311). This prescription includes the overseas branches that Northern medical schools operate in the South (Frenk, et al., 2010, p. 1949). And, indigenous health-centered NGOs partner with many of these same players (see Corbin, Mittlemark, and Lie, 2011, pp. 53–58). For instance, the Thai International Health Policy Program (see Sheikh, et al., 2016, p. 4). In connection with community-research collaborations, Kearsley Stewart (2017, p. 118) notes that “If an experimental intervention cannot be sustained beyond the end of the research study, researchers are now considering broader benefits, such as a new bore hole for clean water, to recognize the contribution of the local community to the research study.” This discussion draws in part upon Koehn and Obamba (2014, pp. 185–191). For other symmetrical and positive, but brief, reports, see Wanni, Hinz, and Day (2010, p. 34) on the Greenwich/Makerere (Uganda) experience and Murphy, et al. (2013, p.  125) on the University of Calgary MPH-capacity-building partnership with the Catholic University of Health and Allied Sciences-Bugando (Tanzania). For three Harvard Medical International (HMI) collaborations in the greater Middle East and Central Asia regions, see Crone (2008, pp. 191–121). On South-South healthnetworking partnerships in Africa funded by Canada’s International Development Research Centre (IDRC), see Sheikh, et al. (2016, pp. 3–4). The partners have been particularly successful in bringing together a large number and diversity of organizations focused on medical-capacity building, health-care promotion, and joint medical research and dissemination. After 2006, AMPATH expanded horizontally and attracted more than 20 additional U.S. academic institutions and organizations into a consortium known as ASANTE (American Sub-Saharan Africa Network for Training and Education). ASANTE is a multi-agency and multidisciplinary consortium that focuses on promoting collaborative medical training and research, providing health care, and strengthening economic-livelihood support for patients (Indiana University, 2010, p. 14). The IUPUI-Moi partnership also has engaged key actors from the corporate, public, philanthropic, and development sectors. Also essential is the emotional-TC skill of “demonstrating respect for, and awareness of, the unique cultures, values, roles/responsibilities and expertise represented by other professionals and groups that work in global health” (Jogerst, et al., 2015, p. 244). For innovative approaches to managing migrant needs for medical treatment and health protection, see Chapter 4. Videotaped presentations that record the extraordinary overseas contributions of committed health professionals in one sparsely populated U.S. state (Montana) can be found at Global Public Health Lecture Series. http://hs.umt.edu/globalpublichealth/ lecture-series/default.php. For an exceptional example of periodic surgical care in rural Guatemala that incorporates follow-up by local health-care providers and email contact when necessary, see Wolfberg (2006, p. 443). For a detailed and illustrated presentation that illuminates Orbis’ role through the experience of one volunteer ophthalmologist, see lecture 6 in the University of Montana’s Global Public Health 2014 lecture series: “The Orbis Flying Eye Hospital: Capacity Building in the Global South” by Dr. Brian Sippy at http://hs.umt.edu/ globalpublichealth/lecture-series/lecture-series-videos-2014.php. “Orbis: What We Do.” www.orbis.org/en/what-we-do; accessed 27 March 2018. Piot notes (2016, p. 11), “The majority of projects . . . have addressed health – both because of real needs in the villages and because global health is a popular area of study today.” See the helpful recommendations provided by John Hawkins (2014, pp. 558, 561, 564–565) based on extensive experience leading “undergraduate ethnographic field schools” for Brigham Young University students in Guatemala and Mexico. Piot’s

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program would satisfy most of Hawkins’ in-field guidelines, most notably the recommendations that students be dispersed geographically and among host families and that the same site be revisited each year. However, no mention is made in Doing Development in West Africa of the importance of evacuation insurance (in order that visiting students “avoid being an immediate source of contagion”), strict injunctions against alcohol consumption and drug usage (potential harm from impaired judgment) and religious or political advocacy, and the need to provide prospective student participants with explicit risk warnings covered by signed statements of understanding (Hawkins, 2014, pp. 562–563, 565; also see Crump and Sugarman, 2008, p. 1457). Piot (2016, pp. 205–206) credits student projects with “nimbleness” that “larger development initiatives lack.” Including, of course, evaluations by stakeholders (see Reisch, 2011, p. 98). All references to the GHC are drawn from “Global Health Corps: Mission and Vision.” https://ghcorps.org/why-were-here/mission-vision/; accessed 27 March 2018. The GHMC could collaborate with the Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health proposed by the Lancet-University of Oslo Commission on Global Governance for Health (see Ottersen, 2014, pp. 631, 659–660). Around the world, “there is an extraordinary reservoir of idealism, good will and determination as well as considerable skill and experience on offer” for work in global health (Crisp, 2016, p. 296; Crisp, 2010, pp. 13, 68). Crisp (2010, p. 68) cites specific examples of persons who would make strong candidates for the GHMC. See, for instance, “Global Health Corps: Mission and Vision.” https://ghcorps.org/ why-were-here/mission-vision/; accessed 27 March 2018. Due to credentialing barriers, many migrants are unable in their present circumstances fully to utilize attributes that would be especially advantageous and respected in the GHMC (see, for instance, Seelye, 2017). In one pilot study conducted in rural Madagascar, Mercy Ships staff successfully prepared non-medically educated Peace Corps volunteers to train local-health-care workers in neonatal resuscitation using the Helping Babies Breathe algorithm (Close, Karel, and White, 2016). Health promotion in this context is defined to include disease-prevention measures such as awareness and vaccination campaigns and sanitation projects (Melby, et al., 2016, p. 636). This focus is shared by the Atlantic Fellows program established through philanthropic contributions donated by Charles F. Feeney. For details, see Atlantic Fellows for Health Equity in South Africa (www.atlanticfellows.org/for-health-equity-in-south-africa/; accessed 18 February 2018); (www.opportunitiesforafricans.com/2017-takano-atlanticfellowship-for-health-equity-in-south-africa-funded/; accessed 18 February 2018); and Atlantic Fellows for Health Equity in Southeast Asia (www.atlanticfellows.org/forhealth-equity-in-southeast-asia/; accessed 18 February 2018). For instance, priority could be placed on projects proposed for countries experiencing the most perilous shortfalls of health-care workers and the largest burdens of refugees and other survival migrants. These principles draw in part upon those I proposed in 1999 for a Development Foundation (see Koehn, 1999, pp. 38–39). For suggested feasible, easily understood, and simple-to-apply selection criteria, see Koehn (1999, pp. 52–55). Preventive, infectious, and chronic health conditions and disparities; health-worker needs; and upstream, midstream, and downstream determinants should be added to this list. This process also is used by the GHC. See “Global Health Corps: Mission and Vision.” https://ghcorps.org/why-were-here/mission-vision/; accessed 27 March 2018. Conducting health-equity-impact assessments for transnational institutions could be assumed as an additional GHMC responsibility.

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33 Stephanie Garbern (2009/2010, p. 41) adds, “How can a physician-patient relationship based on trust and mutual respect, the ideal we hold in the U.S., form in the span of a few months, let alone a single week?” 34 Also “Global Health Corps: Mission and Vision.” https://ghcorps.org/why-were-here/ mission-vision/; accessed 27 March 2018. 35 “Global Health Corps: Mission and Vision.” https://ghcorps.org/why-were-here/ mission-vision/; accessed 27 March 2018 [emphasis in original]. 36 Specifically, “the ability to analyze conflicts, to use non-violent communication, to act in a culturally sensitive manner, and to engage in conflict resolution, negotiation, and mediation” (Arya, Melf, and Buhmann, 2008, pp. 302–309). 37 The Lancet Commission on Education of Health Professionals for the 21st Century notes the importance of “transprofessional teamwork” that includes “basic and ancillary health workers, administrators and managers, policy makers, and leaders of the local community” (Frenk, et al., 2010, pp. 1944, 1948). 38 On specific demonstrations of global health “operational” transnational competencies, see Jogerst, et al. (2015, pp. 243–245). 39 Particularly difficult to assess are potential harms that have been avoided thanks to the project intervention (Lyttleton, 2014, p. 191). 40 Health and humanitarian-relief NGOs, for instance, can model ethical values by “not allowing arms in hospitals, negotiating respect for hospitals and their workers, not using armed guards, not paying for protection, and not paying bribes” (Duggan, 2008, p. 291). 41 This suggestion draws upon recommendation 16.7 of the Commission on Social Determinants of Health’s Final Report (WHO, Commission, 2008, p. 190; also see Pottie and Gruner, 2016, p. 339; Villa-Torres, et al., 2017, p. 78).

References Academic Model Providing Access to Healthcare (AMPATH). 2009. The Indiana-Kenya Partnership. Eldoret, Kenya/Indianapolis, IN: AMPATH Secretariat. Afsana, Kaosar; Demissie Habte; Hatfield, Jennifer; Murphy, Jill; and Neufeld, Victor. 2009. Partnership Assessment Toolkit. Wakefield, QC, Canada: Canadian Coalition for Global Health Research. Appadurai, Arjun. 1996. Modernity at Large: Cultural Dimensions of Globalization. Minneapolis: University of Minnesota Press. Arya, Neil; Melf, Klaus; and Buhmann, Caecilie. 2008. “Educating Health Professionals in Peace.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 301–309. Austin, Ann E.; and Foxcroft, Cheryl. 2011. “Fostering Organizational Change and Individual Learning through ‘Ground-Up’ Inter-Institutional Cross-Border Collaboration.” In Cross-Border Partnerships in Higher Education: Strategies and Issues, edited by Robin Sakamoto and David W. Chapman. New York: Routledge. Pp. 115–132. Bailey, Tracy. 2010. “The Research-Policy Nexus: Mapping the Terrain of the Literature.” Paper prepared for the Higher Education Research and Advocacy Network in Africa (HERANA), Wynberg, UK: Center for Higher Education Transformation. Bammer, Gabriele. 2005. “Integration and Implementation Sciences: Building a New Specialization.” Ecology and Society 10 (2):6. Basilico, Matthew; Kerry, Vanessa; Messac, Luke; Suri, Arjun; Weigel, Jonathan; Basilico, Marguerite T.; Mukherjee, Joia; and Farmer, Paul. 2013. “A Movement for Global Health Equity?” In Reimagining Global Health: An Introduction, edited by Paul Farmer,

Where should we “move” from here? 239 Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 340–353. Bates, Imelda; Taegtmeyer, Miriam; Squire, S. Bertel; Ansong, Daniel; Nhlema-Simwaka, Bertha; Baba, Amuda; and Theobald, Sally. 2011. “Indicators of Sustainable Capacity Building for Health Research: Analysis of Four African Case Studies.” Health Research Policy and Systems 9:14. Becker, Anne; Motgi, Anjali; Weigel, Jonathan; Raviola, Giuseppe; Keshavjee, Salmaan; and Kleinman, Arthur. 2013. “The Unique Challenges of Mental Health and MDRTB.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 212–244. Bikson, Tora K.; Treverton, Gregory F.; Moini, Joy; and Lindstrom, Gustav. 2003. New Challenges for International Leadership: Lessons from Organizations with Global Missions. Santa Monica: Rand Corporation. Boydell, Leslie R.; and Rugkasa, Jorun. 2007. “Benefits of Working in Partnership: A Model.” Critical Public Health 17 (3):217–228. Brada, Betsey B. 2017. “Exemplary or Exceptional? The Production and Dismantling of Global Health in Botswana.” In Global Health and Geographical Imaginaries, edited by Clare Herrick and David Reubi. London: Routledge. Pp. 40–53. Bradley, Megan. 2008. “North-South Research Partnerships: Lessons from the Literature.” NORRAG News 41. Brinkerhoff, Jennifer M. 2002. Partnerships for International Development: Rhetoric or Results? Boulder, CO: Lynne Reinner. Brundiers, Katja; Savage, Emma; Mannell, Steven; Lang, Daniel J.; and Wiek, Arnim. 2014. “Educating Sustainability Change Agents by Design: Appraisals of the Transformative Role of Higher Education.” In Sustainable Development and Quality Assurance in Higher Education: Transformation of Learning and Society, edited by Zinaida Fadeeva, Laima Galkute, Clemens Mader, and Geoff Scott. New York: Palgrave Macmillan. Pp. 196–229. Buhmann, Caecilie; and Pinto, Andrew D. 2008. “Students and Peace through Health: Education, Projects, and Theory.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 293–298. Buss, Paulo M.; and Faid, Miriam. 2013. “Power Shifts in Global Health Diplomacy and New Models of Development: South-South Cooperation.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 305–322. Cahill, Kevin M. 2017. Milestones in Humanitarian Action. New York: Fordham University Press. Campbell, Alex; Sullivan, Maura; Sherman, Randy; and Magee, William P. 2011. “The Medical Mission and Modern Cultural Competency Training.” Journal of the American College of Surgeons 212, No. 1 (January):124–129. Catley-Carlson, Margaret. 2004. “Foundations of Partnerships: A Practitioner’s Perspective.” In Evaluation & Development: The Partnership Dimension, edited by Andres Liebenthal, Osvaldo N. Feinstein, and Gregory K. Ingram. New Brunswick, NJ: Transaction Publishers. Pp. 21–27. Chapin, Erica; and Doocy, Shannon. 2010. “International Short-Term Medical Service Trips: Guidelines from the Literature and Perspectives from the Field.” World Health & Population 12 (2):43–53.

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Where should we “move” from here?

Close, Kristin; Karel, Michele; and White, Michelle. 2016. “A Pilot Program of Knowledge Translation and Implementation for Newborn Resuscitation Using US Peace Corps Volunteers in Rural Madagascar.” Globalization and Health 12 (73). Cole, Donald C.; Hanson, Lori; Rouleau, Katherine D.; Pottie, Kevin; and Arya, Neil. 2013. “Teaching Global Ethics.” In An Introduction to Global Health Ethics, edited by Andrew D. Pinto and Ross E.G. Upshur. London: Routledge. Pp. 148–158. Collins, Christopher S. 2014. “Can Funding for University Partnerships between Africa and the US Contribute to Social Development and Poverty Reduction?” Higher Education 68:943–958. Connell, John. 2014. “The Two Cultures of Health Worker Migration: A Pacific Perspective.” Social Science and Medicine 116:73–81. Corbin, J. Hope; Mittlemark, Maurice B.; and Lie, Gro T. 2011. “Mapping Synergy and Antagony in North-South Partnerships for Health: A Case Study of the Tanzanian Women’s NGO KIWAKKUKI.” Health Promotion International 28 (1):51–60. Cortes, Carlos E.; and Wilkinson, Louise C. 2009. “Developing and Implementing a Multicultural Vision.” In Contemporary Leadership and Intercultural Competence: Exploring the Cross-Cultural Dynamics within Organizations, edited by Michael A. Moodian. Los Angeles: Sage. Pp. 17–31. Crisp, Nigel. 2010. Turning the World Upside Down: The Search for Global Health in the 21st Century. London: Royal Society of Medicine Press. Crisp, Nigel. 2016. One World Health: An Overview of Global Health. Boca Raton, FL: CRC Press. Crone, Robert K. 2008. “Flat Medicine? Exploring Trends in the Globalization of Health Care.” Academic Medicine 83, No. 2 (February):117–121. Crossley, Michael; Herriot, Andrew; Waudo, Judith; Mwirotsi, Miriam; Holmes, Keith; and Juma, Magdallen. 2005. Research and Evaluation for Educational Development: Learning from the PRISM Experience in Kenya. Oxford, UK: Symposium Books. Crossley, Michael; and Holmes, Keith. 2001. “Challenges for Educational Research: International Development, Partnerships and Capacity Building in Small States.” Oxford Review of Education 27 (3):395–409. Crump, John A.; and Sugarman, Jeremy. 2008. “Ethical Considerations for Short-Term Experiences by Trainees in Global Health.” JAMA 300, No. 12 (24 September): 1456–1458. Davies, Sara. 2010. Global Politics of Health. Cambridge, UK: Polity Press. Desha, Cheryl; and Hargroves, Karlson C. 2014. Higher Education and Sustainable Development: A Model for Curriculum Renewal. London: Routledge. Drain, Paul K.; Primack, Aron; Dan, Hunt D.; Fawzi, Wafaie W.; Holmes, King K.; and Gardner, Pierce. 2007. “Global Health in Medical Education: A Call for More Training and Opportunities.” Academic Medicine 82, 3 (March):226–230. Dreifus, Claudia. 2008. “In Professor’s Model, Diversity = Productivity: A Conversation with Scott E. Page.” New York Times, 8 January, p. D2. Duggan, Ann. 2008. “A Role for Emergency Humanitarian Aid Organizations in Peace?” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 287–292. Eckel, Peter D.; and Hartley, Matthew. 2011. “Developing Academic Strategic Alliances: Reconciling Multiple Institutional Cultures, Policies, and Practices.” In Higher Education: Major Themes in Education, Volume 4, edited by Malcolm Tight. London: Routledge. Pp. 199–222.

Introduction 19 medicine assume critical importance (Gunn, 2010, pp. 159, 164–165). In the interest of advancing global health, carefully planned and properly supported alternatives to detention (see Box 2 in Cyril and Renzaho, 2016, pp. 231–232) should receive priority. Health care prospects in northern receiving countries Whether international migration results in overall benefits or losses depends in large measure on the health of migrants in receiving societies (Satyen, et al., 2016, p. 481). Chapter 4 addresses the impact of unequal mobilities on immigration status,45 pre-migration health checks, health status upon arrival, the transmission of infectious disease, host-population receptivity, integration opportunities, workplace health, and health-care prospects in Northern receiving-country contexts. This discussion takes into consideration ways in which the growing emphasis on “securitization” influences conditions that shape migrant-health outcomes. Mavroudi and Nagel (2016, p. 162) treat securitization as “the tendency of modern nation states to construct migration as a security risk and to link migration discursively and in practice to a range of other security problems like terrorism and trafficking.” In general, Southern migrants possess a lower prevalence and incidence of chronic illnesses upon arrival, but this health advantage over established host populations varies according to type of disease, source-country, and length of residence in the North (McMichael, Barnett, and McMichael, 2012, p. 650). Among other considerations, migration-associated explanations for the Hispanic epidemiological paradox (de Leon Siantz, 2016) receive attention in Chapter 4. In light of practical barriers to patient-practitioner match and the absence of prepared staff, migrant-practitioner medical and public-health interactions become particularly challenging both in detention centers and in host-community contexts. The challenges include caring for nearly 23,000 vulnerable unaccompanied minors from multiple countries in Africa who arrived in Europe in 2016 (Sorensen, 2016) and for children separated from their parents on arrival in the USA in 2018 (Carey, 2018). Chapter 4 builds on the discovered value of exploring the experience of illness from the migrant’s perspective. Extending and elaborating Arthur Kleinman’s explanatory model, the benefits of transnationally competent (TC) physical- and mental-health-care interactions on the part of all parties are demonstrated both theoretically and empirically. Promising approaches that negotiate migrant and provider explanatory models of disease causation and prevention (e.g., Palinkas, et al., 2003) also receive scrutiny. The 1986 Ottawa Charter for Health Promotion recognized that “health is created where people live, love, work, and play” (Kickbusch, 1999, p. 452). One’s health place is not immune to transnational influences, however.46 The role of transnational ties, including distant and proximate sending-country consultations and E-health links, is considered in connection with migrant agency and health care in Northern settings. Prospects for future health invasions from the South also are explored in Chapter 4.

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Hoover, Elona. 2015. “Starting from Values: Evaluating Intangible Legacies of CommunityUniversity Research Projects.” www.esdinds.eu Howard, Cynthia R.; Gladding, Sophia P.; Kiguli, Sarah; Andrews, John S.; and John, Chandy C. 2011. “Development of a Competency-Based Curriculum in Global Child Health.” Academic Medicine 86, No. 4 (April):521–527. Hummelbrunner, Richard. 2012. “Process Monitoring of Impacts and Its Application in Structural Fund Programmes.” In Governance by Evaluation for Sustainable Development: Institutional Capacities and Learning, edited by Michal Sedlacko and Andre Martinuzzi. Cheltenham, UK: Edward Elgar. Pp. 253–266. Hussein, Ghaiath; and Upshur, Ross E.G. 2013. “Ethical Challenges in Global Health Research.” In An Introduction to Global Health Ethics, edited by Andrew D. Pinto and Ross E.G. Upshur. London: Routledge. Pp. 103–116. Illingworth, Patricia. 2012. Us before Me: Ethics and Social Capital for Global Well-Being. New York: Palgrave Macmillan. Indiana University. 2010. Indiana University and Moi University Schools of Medicine Partnership: 2010/2011 Orientation Guidebook. Indianapolis: University of Indiana. Ingram, Gregory K. 2004. “Overview.” In Evaluation & Development: The Partnership Dimension, edited by Andres Liebenthal, Osvaldo N. Feinstein, and Gregory K. Ingram. New Brunswick, NJ: Transaction Publishers. Pp. xi–xxi. Janes, Craig R. 2004. “Going Global in Century XXI: Medical Anthropology and the New Primary Health Care.” Human Organization 63 (4):457–471. Jogerst, Kristen; Callender, Brian; Adams, Virginia; Evert, Jessica; Fields, Elise; Hall, Thomas; Olsen, Jody; Rowthorn, Virginia; Rudy, Sharon; Shen, Jiabin; Simon, Lisa; Torres, Herica; Velji, Anvar; and Wilson, Lynda L. 2015. “Identifying Interprofessional Global Health Competencies for 21st-Century Health Professionals.” Annals of Global Health 81 (2):239–248. Johansson, Frans. 2004. The Medici Effect. Cambridge: Harvard Business School Press. Johnson, Oliver; Bailey, Sarah L.; Willott, Chris; Crocker-Buque, Tim; Jessop, Vanessa; Birch, Marion; Ward, Helen; and Yudkin, John S. 2012. “Global Health Learning Outcomes for Medical Students in the UK.” Lancet 379 (2 June):2033–2035. Johnstone, D. Bruce; and Marcucci, Pamela N. 2010. Financing Higher Education Worldwide: Who Pays? Who Should Pay? Baltimore: Johns Hopkins University Press. Jones, Nicola; Bailey, Mark; and Lyytikäinen, Minna. 2007. Research Capacity Strengthening in Africa: Trends, Gaps and Opportunities. London: Overseas Development Institute. Kanth, Priyanka; Gleicher, David; and Guo, Yan. 2013. “National Strategies for Global Health.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 285–303. Kerry, Vanessa B.; Auld, Sara; and Farmer, Paul. 2010. “An International Service Corp for Health: An Unconventional Prescription for Diplomacy.” New England Journal of Medicine 363 (13):1199–1202. Kickbusch, Ilona. 2015. “The Political Determinants of Health—10 Years On.” British Medical Journal 350:h81. Kickbusch, Ilona. 2017. “The New Director General of WHO and the Politics of Global Health.” BMJ Opinion, 31 May. Kickbusch, Ilona; Novotny, Thomas E.; Drager, Nico; Silberschmidt, Gaudenz; and Alcazar, Santiago. 2007. “Global Health Diplomacy: Training across Disciplines.” Bulletin of the World Health Organization 85, No. 12 (December):971–972.

Where should we “move” from here? 243 Kinser, Kevin; and Green, Madeleine. 2009. The Power of Partnerships: A Transatlantic Dialogue. Washington, DC: American Council on Education. Kleinman, Arthur; Eisenberg, Leon; and Good, Byron. 1978. “Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research.” Annals of Internal Medicine 88:251–258. Koehn, Peter H. 1999. “Operationalizing the Development-Fund Model: Suggestions for Managing Channeled Aid.” In Making Aid Work: Innovative Approaches for Africa at the Turn of the Century, edited by Peter H. Koehn and Olatunde J.B. Ojo. Lanham, MD: University Press of America. Pp. 37–74. Koehn, Peter H. 2005a. “Improving Transnational Health-Care Encounters and Outcomes: The Challenge of Enhanced Transnational Competence for Migrants and Health Professionals.” Proceedings of the Hospitals in a Culturally Diverse Europe Conference on Quality-Assured Health Care and Health Promotion for Migrants and Ethnic Minorities, Amsterdam, 9–11 December 2004. www.mfh-eu.net/conf/results/ Koehn, Peter H. 2005b. “Medical Encounters in Finnish Reception Centres: AsylumSeeker and Clinician Perspectives.” Journal of Refugee Studies 18 (1):47–74. Koehn, Peter H. 2006a. “Globalization, Migration Health, and Educational Preparation for Transnational Medical Encounters.” Globalization and Health 2 (2):1–43. Koehn, Peter H. 2006b. “Health-Care Outcomes in Ethnoculturally Discordant Medical Encounters: The Role of Physician Transnational Competence in Consultations with Asylum Seekers.” Journal of Immigrant and Minority Health 8, No. 2 (April): 137–147. Koehn, Peter H.; and Obamba, Milton O. 2014. The Transnationally Partnered University: Insights from Research and Sustainable Development Collaborations in Africa. Gordonsville, VA: Palgrave Macmillan. Koehn, Peter H.; and Rosenau, James N. 2010. Transnational Competence: Empowering Professional Curricula for Horizon-Rising Challenges. Boulder, CO: Paradigm Publishers. Koehn, Peter H.; and Swick, Herbert. 2006. “Medical Education for a Changing World: Moving Beyond Cultural Competence into Transnational Competence.” Academic Medicine 81, No. 6 (June):548–556. Koehn, Peter H.; and Uitto, Juha I. 2017. Universities and the Sustainable Development Future: Evaluating Higher-Education Contributions to the 2030 Agenda. London: Routledge. Labonte, Ronald. 2013. “Human Rights and Equity: The Value Base of Global Health Diplomacy.” In Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases, edited by Ilona Kickbusch, Graham Lister, Michaela Told, and Nick Drager. New York: Springer. Pp. 89–105. Langowski, Michele K.; and Iltis, Ana S. 2011. “Global Health Needs and the Short-Term Medical Volunteer: Ethical Considerations.” HEC Forum 23:71–78. Larkan, Fiona; Uduma, Ogenna; Lawal, Saheed A.; and van Bavel, Bianca. 2016. “Developing a Framework for Successful Research Partnerships in Global Health.” Globalization and Health 12:17–25. Lencucha, Raphael; and Mohindra, Katia. 2014. “A Snapshot of Global Health Education in North American Universities.” Global Health Promotion 21 (1):63–67. Li, Fei-fei. 2018. “How to Make A.I. Human-Friendly.” New York Times, 8 March, p. A27. Lyon, Evan; Kim, Jim Yong; and Farmer, Paul. 2008. “Social Injustice and the Responsibility of Health-Care Workers: Observation, Assessment, Action.” In Peace through Health: How Health Professionals Can Work for a Less Violent World, edited by Neil Arya and Joanna Santa Barbara. Sterling, VA: Kumarian Press. Pp. 267–275.

244

Where should we “move” from here?

Lyttleton, Chris. 2014. Intimate Economies of Development: Mobility, Sexuality and Health in Asia. London: Routledge. Mackey, Tim K.; and Liang, Bryan A. 2013. “Restructuring Brain Drain: Strengthening Governance and Financing for Health Worker Migration.” Global Health Action 6 (19923). Mader, Clemens. 2014. “The Role of Assessment and Quality Management in Transformations towards Sustainable Development: The Nexus between Higher Education, Society and Policy.” In Sustainable Development and Quality Assurance in Higher Education: Transformation of Learning and Society, edited by Zinaida Fadeeva, Laima Galkute, Clemens Mader, and Geoff Scott. New York: Palgrave Macmillan. Pp. 66–83. Maki, Jesse; Qualls, Munirih; White, Benjamin; Kleefield, Sharon; and Crone, Robert. 2008. “Health Impact Assessment and Short-Term Medical Missions: A Methods Study to Evaluate Quality of Care.” BMC Health Services Research 8 (2). Marten, Robert; and Witte, Jan M. 2008. “Transforming Development? The Role of Philanthropic Foundations in International Development Cooperation.” GPPi Research Paper Series No. 10. Berlin: Global Public Policy Institute. Martin, Susan F.; Davis, Rochelle; Benton, Grace; and Waliany, Zoya. 2017. “Responsibility Sharing for Refugees in the Middle East and North Africa: Perspectives from Policymakers, Stakeholders, Refugees and Internally Displaced Persons.” Report 2017:8. Stockholm: Delmi, The Migration Studies Delegation. Martiniuk, Alexandra L.; Manouchehrian, Mitra; Negin, Joel A.; and Zwi, Anthony B. 2012. “Brain Gains: A Literature Review of Medical Missions to Low and MiddleIncome Countries.” Health Services Research 12 (134). Mavroudi, Elizabeth; and Nagel, Caroline. 2016. Global Migration: Patterns, Processes, and Politics. London: Routledge. McCall, Daniel; and Iltis, Ana S. 2014. “Health Care Voluntourism: Addressing Ethical Concerns of Undergraduate Student Participation in Global Health Volunteer Work.” HEC Forum 26:285–297. McCracken, Kevin; and Phillips, David R. 2017. Global Health: An Introduction to Current and Future Trends. London: Routledge. McMahon, Walter W. 2009. Higher Learning, Greater Good: The Private and Social Benefits of Higher Education. Baltimore: Johns Hopkins University Press. McMichael, Anthony J. 2013. “Globalization, Climate Change, and Human Health.” New England Journal of Medicine 368:1335–1343. McMichael, Celia; Barnett, Jon; and McMichael, Anthony J. 2012. “An Ill Wind? Climate Change, Migration, and Health.” Environmental Health Perspectives 120, No. 5 (May):646–654. Melby, Melissa K.; Loh, Lawrence C.; Evert, Jessica; Prater, Christopher; Lin, Henry; and Khan, Omar A. 2016. “Beyond Medical ‘Missions’ to Impact-Driven Short-Term Experiences in Global Health (STEGHs): Ethical Principles to Optimize Community Benefit and Learner Experience.” Academic Medicine 91, No. 5 (May):633–639. Moran, Robert T.; Harris, Philip R.; and Moran, Sarah V. 2007. Managing Cultural Differences: Global Leadership Strategies for the 21st Century. Amsterdam: Elsevier. Muir, Jonathan A.; Farley, Jessica; Osterman, Allison; Hawes, Stephen E.; Martin, Keith; Morrison, J. Stephen; and Holmes, King K. 2016. Global Health Programs and Partnerships: Evidence of Mutual Benefit and Equity. Lanham, MD: Rowman & Littlefield. Mullan, Fitzhugh; Panosian, Claire; and Cuff, Patricia (eds.). 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: National Academy Press.

Where should we “move” from here? 245 Murphy, Jill; Neufeld, Victor R.; Demissie Habte; Abraham Asseffa; Afsana, Kaosar; Kumar, Anant; Larrea, Maria de Lourdes; and Hatfield, Jennifer. 2013. “Ethical Considerations in Global Health Partnerships.” In An Introduction to Global Health Ethics, edited by Andrew D. Pinto and Ross E.G. Upshur. London: Routledge. Pp. 117–128. Oakley, Peter. 1991. Projects with People: The Practice of Participation in Rural Development. Geneva: International Labor Office. Obamba, Milton O.; Mwema, Jane K.; and Riechi, Andrew R. 2011. University Partnerships Can Reduce Poverty. ANIE Policy Brief. Accra: Association of African Universities. Omaswa, Francis; and Crisp, Nigel. 2014. “Introduction to Part I: Overview.” In African Health Leaders: Making Change and Claiming the Future, edited by Francis Omaswa and Nigel Crisp. Oxford: Oxford University Press. Pp. 3–8. Ottersen, Ole P.; and 23 co-authors. 2014. “The Political Origins of Health Inequity: Prospects for Change.” Lancet 383 (15 February):630–667. Page, Scott E. 2007. The Difference: How the Power of Diversity Creates Better Groups, Firms, Schools, and Societies. Princeton: Princeton University Press. Penttinen, Elina; and Kynsilehto, Anita. 2017. Gender and Mobility: A Critical Introduction. London: Rowman & Littlefield. Piot, Charles (ed.). 2016. Doing Development in West Africa: A Reader By and For Undergraduates. Durham, DC: Duke University Press. Poister, Theodore H.; Aristigueta, Maria P.; and Hall, Jeremy L. 2015. Managing and Measuring Performance in Public and Nonprofit Organizations: An Integrated Approach, 2nd edition. San Francisco, CA: Jossey Bass. Pottie, Kevin; and Gruner, Doug. 2016. “Health Equity: Evidence-Based Guidelines, E-Learning and Physician Advocacy for Migrant Populations in Canada.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 329–343. Pottie, Kevin; Hui, Chuck; and Schneider, Fabien. 2016. “Women, Children and Men Trapped in Unsafe Corridors.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 291–303. Powell, Steve; Molander, Joakim; and Celebicic, Ivona. 2012. “Assessment of Outcome Mapping as a Tool for Evaluating and Monitoring Support to Civil Society Organisations.” In Governance by Evaluation for Sustainable Development: Institutional Capacities and Learning, edited by Michal Sedlacko and Andre Martinuzzi. Cheltenham, UK: Edward Elgar. Pp. 215–232. Ravetz, Joe. 2007. “The Role of Evaluation in Regional Sustainable Development.” In Impact Assessment and Sustainable Development: European Practice and Experience, edited by Clive George and Colin Kirkpatrick. Cheltenham, UK: Edward Elgar. Pp. 65–89. Redwood-Campbell, Lynda; Pakes, Barry; Rouleau, Katherine; MacDonald, Colla J.; Arya, Neil; Purkey, Eva; Schultz, Karen; Dhatt, Reena; Wilson, Briana; Hadi, Abdullahel; and Pottie, Kevin. 2011. “Developing a Curriculum Framework for Global Health in Family Medicine: Emerging Principles, Competencies, and Educational Approaches.” BMC Medical Education 11 (46). Reisch, Rebecca A. 2011. “International Service Learning Programs: Ethical Issues and Recommendations.” Developing World Bioethics 11 (2):93–98. Renzaho, Andre M.N. 2016. “Health, Social and Economic Impact of Voluntary Migration.” In Globalisation, Migration and Health: Challenges and Opportunities, edited by Andre M.N. Renzaho. London: Imperial College Press. Pp. 123–203. Rist, Ray C. 2013. “Postscript–Evaluation and Turbulence: Beyond an Incremental View of the World.” In Evaluation and Turbulent Times: Reflections on a Discipline in Disarray,

246

Where should we “move” from here?

edited by Jan-Eric Furubo, Ray C. Rist, and Sandra Speer. New Brunswick, NJ: Transaction Publishers. Pp. 255–262. Roberts, Liam. 2005. “African Higher Education Development and the International Community.” Short Paper Series on African Higher Education Development. London: Policy Research Unit, Association of Commonwealth Universities, June. Rosenau, James N. 1992. “Normative Challenges in a Turbulent World.” Ethics and International Affairs 6 (December):1–19. Rowe, Debra; and Hiser, Krista. 2016. “Higher Education for Sustainable Development in the Community and through Partnerships.” In Routledge Handbook of Higher Education for Sustainable Development, edited by Matthias Barth, Gerd Michelsen, Marco Rieckmann, and Ian Thomas. London: Routledge. Pp. 315–330. Samoff, Joel; and Carrol, Bidemi. 2004. “The Promise of Partnership and Continuities of Dependence: External Support to Higher Education in Africa.” African Studies Review 47 (1):67–199. Sanchez, Ana; and Lopez, Victor A. 2013. “Perspectives on Global Health from the South.” In An Introduction to Global Health Ethics, edited by Andrew D. Pinto and Ross E.G. Upshur. London: Routledge. Pp. 129–135. Sande, Merle; and Ronald, Allan. 2008. “The Academic Alliance for AIDS Care and Prevention in Africa.” Academic Medicine 83 (2):180–184. Schuller, Tom; and Desjardins, Richard. 2007. Understanding the Social Outcomes of Learning. Paris: Organization for Economic Co-Operation and Development (OECD). Schuller, Tom; Hammond, Cathie; and Preston, John. 2004. “Reappraising Benefits.” In The Benefits of Learning: The Impact of Education on Health, Family Life and Social Capital, edited by Tom Schuller, John Preston, Cathie Hammond, Angela Brassett-Grundy, and John Bynner. London: RoutledgeFalmer. Pp. 179–193. Sears, Karen P. 2012. “Improving Cultural Competence Education: The Utility of an Intersectional Framework.” Medical Education 46:545–551. Seelye, Katherine Q. 2017. “In Search of Immigrants to Help in Emergencies.” New York Times, 28 March, p. A12. Sen, Amartya. 1999. Development as Freedom. New York: Anchor Books. Sheikh, Kabir; Schneider, Helen; Agyepong, Irene A.; Lehmann, Uta; and Gilson, Lucy. 2016. “Boundary-Spanning: Reflections on the Practices and Principles of Global Health.” BMJ Global Health 1. DOI: 10.1136/bmjgh-2016-000058 Shuman, Larry J.; Besterfield-Sacre, Mary; and McGourty, Jack. 2005. “The ABET ‘Professional Skills’: Can They Be Taught? Can They Be Assessed?” Journal of Engineering Education 94 (1):41–53. Sidibe, Michel; and Campbell, James. 2015. “Reversing a Global Workforce Crisis.” Bulletin of the World Health Organization 93:3. Singh, Mala. 2007. “Universities and Society: Whose Terms of Engagement?” In Knowledge Society vs. Knowledge Economy: Knowledge, Power, and Politics, edited by Sverker Sorlin and Hebe Vessuri. Hampshire: Palgrave Macmillan. Pp. 53–78. Smedley, Brian D.; Stith, Adrienne Y.; and Nelson, Alan R. (eds.). 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press. Smith, Harvey. 2000. “Transforming Education through Donor-Funded Projects: How Do We Measure Success?” In Globalisation, Educational Transformation and Societies in Transition, edited by Teame Mebrahtu, Michael Crossley, and David Johnson. Oxford: Symposium Books. Pp. 207–218.

Where should we “move” from here? 247 Stern, Elliot. 2004. “Evaluating Partnerships.” In Evaluation & Development: The Partnership Dimension, edited by Andres Liebenthal, Osvaldo N. Feinstein, and Gregory K. Ingram. New Brunswick, NJ: Transaction Publishers. Pp. 29–41. Stewart, Kearsley A. 2017. “Anthropological Perspectives in Bioethics.” In International Encyclopedia of Public Health, 2nd edition, edited by Stella R. Quah. Amsterdam: Academic Press. Pp. 113–121. Stockmann, Reinhard. 2012. “Understanding Sustainability Evaluation and Its Contributions to Policy-Making.” In Sustainable Development, Evaluation and Policy-Making: Theory, Practise and Quality Assurance, edited by Anneke von Raggamby and Frieder Rubik. Cheltenham, UK: Edward Elgar. Pp. 3–20. Stone, Diane. 2004. “Research Partnerships and Their Evaluation.” In Evaluation & Development: The Partnership Dimension, edited by Andres Liebenthal, Osvaldo N. Feinstein, and Gregory K. Ingram. New Brunswick, NJ: Transaction Publishers. Pp. 149–160. Suarez-Orozco, Marcelo M.; and Qin-Hilliard, Desiree B. 2004. “Globalization: Culture and Education in the New Millennium.” In Globalization: Culture and Education in the New Millennium, edited by Marcelo M. Suarez-Orozco and Desiree B. Qin-Hilliard. Berkeley: University of California Press. Pp. 1–37. Suri, Arjun; Weigel, Jonathan; Messac, Luke; Basilico, Marguerite T.; Basilico, Matthew; Hanna, Bridget; Keshavjee, Salmaan; and Kleinman, Arthur. 2013. “Values and Global Health.” In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Berkeley: University of California Press. Pp. 245–286. Syed, Shamsuzzoha B.; Dadwal, Viva; Rutter, Paul; Storr, Julie; Hightower, Joyce D.; Gooden, Rachel; Carlet, Jean; Nejad, Sepideh B.; Kelley, Edward T.; Donaldson, Liam; and Pittet, Didier. 2012. “Developed-Developing Country Partnerships: Benefits to Developed Countries?” Globalization and Health 8 (17). DOI: 10.1186/1744-8603-8-17 Sykes, Kevin J. 2014. “Short-Term Medical Trips: A Systematic Review of the Evidence.” Systematic Review 104 (7):e38–e48. Tarabini, Aina. 2010. “Education and Poverty in the Global Development Agenda: Emergence, Evolution and Consolidation.” International Journal of Education and Development 30 (2):204–212. Terrazas, Aaron. 2010. “Connected through Service: Diaspora Volunteers and Global Development.” In Diasporas: New Partners in Global Development Policy, edited by Kathleen Newland. Washington, D.C.: Migration Policy Institute. Pp. 162–211. Thabrew, Lanka; Wiek, Arnim; and Ries, Robert. 2009. “Environmental Decision Making in Multi-Stakeholder Contexts: Applicability of Life Cycle Thinking in Development Planning and Implementation.” Journal of Cleaner Production 17:67–76. Tiessen, Rebecca. 2018. Learning and Volunteering Abroad for Development: Unpacking Host Organization and Volunteer Rationales. London: Routledge. Toole, Michael. 2006. “Forced Migrants: Refugees and Internally Displaced Persons.” In Social Injustice and Public Health, edited by Barry S. Levy and Victor W. Sidel. Oxford: Oxford University Press. Pp. 190–204. United Nations Development Programme (UNDP). 2011. “Main Outcomes of the International Conference on National Evaluation Capacities.” In National Evaluation Capacities 2009. Proceedings from the International Conference on National Evaluation Capacities, Casablanca, Kingdom of Morocco, 15–17 December 2009. New York: UNDP Evaluation Office. Pp. 8–11.

248

Where should we “move” from here?

Upshur, Ross E.G.; Benatar, Solomon; and Pinto, Andrew D. 2013. “Ethics and Global Health.” In An Introduction to Global Health Ethics, edited by Andrew D. Pinto and Ross E.G. Upshur. London: Routledge. Pp. 16–35. Uretsky, Elanah. 2016. Occupational Hazards: Sex, Business, and HIV in Post-Mao China. Stanford, CA: Stanford University Press. Villa-Torres, Laura; Gonzalez-Vazquez, Tonatiuh; Fleming, Paul J.; Gonzalez-Gonzalez, Edgar L.; Infante-Xibille, Cesar; Chavez, Rebecca; and Barrington, Clare. 2017. “Transnationalism and Health: A Systematic Literature Review on the Use of Transnationalism in the Study of the Health Practices and Behaviors of Migrants.” Social Science and Medicine 183:70–79. Waitzkin, Howard. 1991. The Politics of Medical Encounters: How Patients and Doctors Deal with Social Problems. New Haven: Yale University Press. Walker, Melanie; McLean, Monica; Dison, Arona; and Peppin-Vaughn, Rosie. 2009. “South African Universities and Human Development: Towards a Theorisation and Operationalisation of Professional Capabilities for Poverty Reduction.” International Journal of Educational Development 29:565–572. Walsh, Lorraine; and Kahn, Peter. 2010. Collaborative Working in Higher Education: The Social Academy. New York: Routledge. Walton-Roberts, Margaret. 2015. “International Migration of Health Professionals and the Marketization and Privatization of Health Education in India: From Push-Pull to Global Political Economy.” Social Science & Medicine 124:374–382. Wanni, Nada; Hinz, Sarah; and Day, Rebecca. 2010. Good Practices in Educational Partnerships Guide: UK-Africa Higher & Further Education Partnerships. London: ACU, Africa Unit. Ward, Terence; and Pucci, Idanna. 2017. “IDHA 3.” In Milestones in Humanitarian Action, edited by Kevin M. Cahill. New York: Fordham University Press. Pp. 112–119. Werdell, Philip. 1974. “Futurism and the Reform of Higher Education.” In Learning for Tomorrow: The Role of the Future in Education, edited by Alvin Toffler. New York: Vintage Books. Pp. 272–311. Were, Miriam K. 2014. “Community Health, Community Workers, and Community Governance.” In African Health Leaders: Making Change and Claiming the Future, edited by Francis Omaswa and Nigel Crisp. Oxford: Oxford University Press. Pp. 109–124. Withers, Mellissa; Browner, Carole H.; and Aghaloo, Tara. 2013. “Promoting Volunteerism in Global Health: Lessons from a Medical Mission in Northern Mexico.” Journal of Community Health 38:374–384. Wolfberg, Adam J. 2006. “Volunteering Overseas: Lessons from Surgical Brigades.” New England Journal of Medicine 354, No. 5 (2 February):443–445. World Health Organization (WHO). 2010. Health of Migrants: The Way Forward. Report of a Global Consultation Held in Madrid, Spain, 3–5 March. Geneva: World Health Organization. World Health Organization (WHO). 2016. Global Strategy on Human Resources for Health: Workforce 2030. Geneva: World Health Organization. World Health Organization (WHO), Commission on Social Determinants of Health. 2008. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: World Health Organization. Zint, Michaela. 2011. “Evaluating Education for Sustainable Development Programs.” In World Trends in Education for Sustainable Development, edited by Walter L. Filho. Frankfurt: Peter Lang. Pp. 329–347. Zuger, Abigail. 2016. “Book Review: ‘Hoping to Help’ Questions Value of Volunteers.” New York Times, 25 April.

Index

Academic Model Providing Access to Healthcare (AMPATH) 209–211, 236 accompaniment foreign-assistance strategy 153 active listening 124 acute stress disorder 98 additionality 208–209, 218, 227 advertising 15, 20, 148; see also marketing of harmful commodities Affordable Health Care Act see United States Afghanistan 17, 27, 65, 71 Africa xi, xiv–xv, 5, 19–20, 25–27, 38–39, 45, 51–52, 65, 84, 131, 152, 156–158, 161–163, 173, 204, 207, 215, 222–223, 236; East Africa 43, 96, 153, 197; Horn of Africa 60; southern Africa 153; West Africa xv–xvi, 43, 96, 152, 181, 183 African Development Bank 163 African Diaspora Programme: Database of Professional Skills in the African Diaspora 218 African migrants xv, 74, 91 African philanthropists 163 African Union 74, 163; Executive Council 11; Kampala Convention 27 Agenda 2030 see sustainable-development, goals and targets Agenda for the Protection of Cross-Border Displaced Persons in the Context of Disasters and Climate Change 92 AIDS see HIV/AIDS air connectivity 48; see also air travel air pollution 188–190, 192, 197; coal soot 188; consumer demand 192, 197; Global Burden of Disease report 188; motor vehicle emissions/operation 188, 192, 197; UNDP-WHO study 188; WHO’s airborne-particulate standards 188

air quality index app 189 air travel 42, 48, 173, 176; see also air connectivity Ai Weiwei 1 alcohol consumption/usage 9, 106, 110, 112, 162, 237 Algeria 21 al-Hussein, Zeid Ra’ad see U.N. High Commissioner for Human Rights allied-health workers 156 al-Muderis, Munjed 149 alternative medicine/therapies 41–42, 51, 108, 110, 128, 213; see also traditional medicine Alves, Maria Thereza: 2016 Vera List Center Prize for Art and Politics 26; floating gardens 26; Seeds of Change projects 14 American International Health Alliance: HIV/AIDS Twinning Center, Volunteer Health Corps initiative 164 American Sub-Saharan Africa Network for Training and Education (ASANTE) 236 Amnesty International (AI) 71 Amsterdam Declaration Towards MigrantFriendly Hospitals in an Ethno-culturally Diverse Europe 135; see also migrantfriendly-hospital(s) Angola 157, 177 Antarctica: ice sheets 86, 190–191 anti-ageing treatment 41 antipyretic drugs xv antiretroviral therapy 88, 133 armed conflict 2, 15, 17–18, 26, 58–66, 72, 84, 115, 155, 222–224, 234 artificial intelligence (A.I.) 212–213 Asia xiv, 26, 38–39, 41–42, 52, 171–172; Central Asia 173, 236; East Asia xi; Southeast Asia 20, 51, 157, 223

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Index

Association of Nigerian Physicians in the Americas (ANPA) 160 asylum applications (USA) 25, 67 asylum seekers xi, xv, 27, 38, 58, 71, 75, 93, 98, 105, 109, 133, 220 Atlantic Fellows for Health Equity: in South Africa 223, 237; in Southeast Asia 223, 237 attribution arguments 190, 197 Australia 109, 156, 214; offshoreprocessing centers 71 Baghdad 149 Bangladesh 18, 70, 86, 194; Dhaka 194; Rohingya refugees 18, 70, 97, 113, 191 basic health care units 68–69 Benin 157 bilateral donors see donor agencies Bill and Melinda Gates Foundation 26 biosecurity 47–48, 171–172 bioterrorism 12 border-enforcement initiatives 90 Boston 39 Botswana 38 boundary interfaces 14 boundary spanning 114, 148 brain circulation 218 brain drain 17, 159, 218 brain gain 159, 218 brain waste 21, 27, 159, 164; see also deskilling; reskilling Brazil 158, 163 Brigham Young University 236 Bulgaria: Tokuda Hospital Sofia 41 Bush, Barbara see Global Health Corps California 38, 90; farm workers 105–106; northern California fires of 2017 88; Salinas Valley 106; San Francisco 97, 134; Santa Rosa 88 Cambodia 46, 61, 183 Cambodian refugees 68 Cameroon 157 Canada 5, 25, 73, 109, 134, 156, 214; International Development Research Centre (IDRC) 236 Canadian medical tourists 42–43, 129 Canadian Red Cross 68 cardiac rehabilitation 122 care-provider/recipient match 19, 110, 118, 128; ethnic 112, 118; nationality 112 Caribbean 41, 173 Carnegie Foundation 208; see also philanthropic bodies

Catholic University of Health and Allied Sciences-Bugando (Tanzania) 236 Center for International Humanitarian Cooperation 74, 223; International Diploma in Humanitarian Assistance (IDHA) 223; see also Somaliland Central American migrants 27, 134 Centre for HIV/AIDS Networking (HIVAN) 208 Centre for Research on the Epidemiology of Disasters (CRED) 96 Chad 21 Chigwedere, Pride 158 China 2, 24–25, 41, 45, 49, 51, 86, 134, 187–193, 197–198, 232; airpocalypse 189, 193; Beijing 152, 188–189, 192; Beijing Saint Lucia Hospital Management Consulting Company 49; biking 197; China Central Television (CCTV) 189; co-benefits framing 192; fuel-economy standards 197; Guangzhou 191; Harbin 188; Hope Noah Health Company 49; household consumption 192, 197; issue bundling 192; low-carbon living 192; Luna New Year journeys 24; millionaires 193; motor-vehicle usage 192; Ningxia Hui Autonomous Region 188; Premier Li Keqiang 189; President Xi Jinping 190; Ryavo Health Management of Shanghai 49; Shanghai Academy of Social Sciences 192; Shijiazhuang 188; subnational authorities 192; Tianjin 191 Chinese diaspora transnationals 198 cholera 64–65, 68, 89, 175 Chu, Stephen 86, 191 circular migrants/migration 20, 24, 148, 158–162, 218–219, 234 civilian casualties 2, 26, 62, 223 civil-society citizenship 131 clean/safe water 39, 63, 68–73, 85–86, 89–90, 151, 154, 159, 191, 194–196, 210–211, 221, 236 climate migrants see environmental migrants climate migration 195–196 climate-sustaining actions 197 clinical breast examination (CBE) 134 Clinton Health Access Initiative (CHAI) 153 closing plan see exit strategy CO2 emissions see GHG emissions coastal cities 86, 194 colonialism xiv

Index commercialization of health care 17, 40, 49 Commission on Global Governance for Health see Lancet-University of Oslo Commission on Global Governance for Health Commission on Twenty-first Century Global Health and Mobility Challenges 235 commodification of health care 49; see also commercialization of health care; marketing of harmful commodities community-health workers 122, 155, 157, 204–205 community mental-health workers 69 conflict management 230 contact tracing 175, 182 continuity of care 42, 44, 96, 129, 214, 231, 236 cooperative agreements 43 COP21 see Paris Agreement adopted at the Conference of Parties to the United Nations Framework Convention on Climate Change cost-effectiveness analysis 225 creative synthesizers 121, 211 credential (re)certification 126, 207 credentialing barriers 237 crisis of care 129 cross-border marriages 25 Cuba 13, 42, 46, 51, 158, 206 Cuban health workers 158, 163, 236 cultural blind spot syndrome 118 cultural brokers see intercultural mediators customs agents 176–177 cyberspace 160 Cyclone Aila (2009) 194 Dallas 176 Dargis, Manohla 1 deep-structure communication 124 deep trust 230 deforestation see habitat alterations Democratic Republic of Congo (DRC) 61, 63, 67; Nganza 74 demographic counter-penetration see Mazrui, Ali dengue fever 39, 85, 89 Denmark 116 dental care 129 dentists 156 dermatological problems 39–40 desertification 188 deskilling 21; see also brain waste; reskilling

251

detention centers 18–19, 71, 93–94, 98, 105, 110; alternatives to 94–95 de-territorializing 205 development agencies 208, 216 “development”-excused displacement 86 diarrheal diseases 67–68 diaspora associations 220 diaspora contributions 148, 158–159, 196 diaspora professionals 159–162, 218–219; see also African Diaspora Programme: Database of Professional Skills in the African Diaspora diasporic communities viii digital divide 153; digital inequalities 129; see also Internet disaster-risk-reduction 91, 95 disease-specific interventions 153 Doctors Without Borders see Médecins Sans Frontières domestic-animal husbandry 172 Donald Trump Administration: 2017 annual refugee admissions limit 75; 2017 travel ban 27; 2018 deployment National Guard troops 134–135; climate actions 197; deportation orders 107; overseas health worker evacuations 179–180, 183; Temporary Protected Status program 133; zero tolerance policy xi donor agencies 11, 26, 75, 97, 155, 175, 208, 220, 230, 232 drought 84, 96, 188, 197–199 drug treatments: interruptions in 85 dual citizenship 134 Dubai 26, 45; Dubai Health Care City 43 Duke University 215–217; DukeEngage program 217; Global Health Institute 217 Duncan, Thomas E. 176–178 early-warning mechanisms/systems 91, 179, 198 Ebola 13, 172, 177; 2014/2015 epidemic xv, 20–21, 65, 152, 163, 174–181, 183, 205; see also ERIDs ecological migrants see environmental migrants E-health 19, 23, 39, 48–50, 104, 125, 129 electricity schemes 85–86, 152, 154 El Salvador 73; gang violence and extortion 133 Emirates see United Arab Emirates empathy 2, 119–121 environmental migrants 22, 187–188, 194–197

252

Index

environmental stress and disaster 82 epidemic(s) xii, 21, 68, 83, 89, 151–152, 157, 172–173, 176–177, 181–183, 205, 224 epidemiological transition 9 epidemiologists 107, 174 ERIDs 13, 21, 152, 171–177, 180–183 Eritrea 60, 71, 74; President Isaias Afewerki 219; Provisional Government 219 Eritrean People’s Liberation Front (EPLF) 219 Eritrean refugees 60–61, 75, 219 Eritreans in Israel 97 essential health benefit (EHB) approach 153 Ethiopia 74, 157, 219; Addis Ababa 218–219; Eritrean refugees and asylum seekers 74–75; health system 161; highlanders 198; Ministry of Finance 219; Oromia 65; outmigration 60–61 Ethiopians in Saudi Arabia 97 ethnic cleansing 61, 74 ethnography 116–117, 134 ethnopharmacology 117 Europe viii, xiv, 13, 19, 26, 43, 45, 52, 60, 67, 71, 87–88, 91, 93, 130, 132, 149, 180; Western Europe 214 Europeans xiv–xv European Union 1, 38, 43, 74, 87, 192, 194 evacuation of medical personnel 179–180, 183; see also Hickox, Kaci; Trump, Donald evacuation of populations 87, 191 evaluation: 360-degree 227; chain of impact 232; collaborative 204, 225, 229–231; ethnographic inquiries 232; GHMC initiatives 225, 232; impact 23–24, 217, 221, 225–228, 232–233, 236; input 225–228, 232; outcome 23–24, 217, 221, 225–228, 230, 232–233; output 225–226, 228, 232; partnership 226, 228, 230–232; process 225, 229; project 221, 226, 232–233; summative 225; transnational-competency 226–227; triangulation 231 exit strategy(ies) 153, 217, 220–221, 223, 230 explanatory framework 112, 118; alternative 121, 213; biomedical 122, 213; biopsychosocial 115; ethnocultural 121, 213 explanatory model(s) [EMs] (Kleinman) 19, 110–111, 113

Facebook posts 21 failed states 66, 70 faith-based organizations 10 family-support networks 178 fatal flow of expertise 9, 20, 155–157 fear and panic 172, 182 Feeney, Charles F. see Atlantic Fellows for Health Equity Finland 73, 134; Finnish physicians 130 Finnish Red Cross (FRC) 68–69; basic health care units (BHU) 68–69 follow-up care see continuity of care food insecurity 13, 86, 96, 196–197; see also drought forcible return 134; see also repatriation foreign policy 26, 114, 220 Fortis Parkway group 52 foundations 10, 26, 208, 228 frequent flyers: health challenges 4 Frieden, Thomas R. 180 Fukushima nuclear accident of 2011 87; evacuee decision making 87 G8 26 Gates, Bill 183 gender-based violence 62–63, 67 generalized anxiety disorder 98 Geneva Conventions of 1949 61 genogram construction 134 Georgetown University xii–xiii GeoSentinel 39, 48 Germany 43, 46; Essen University Hospital 45–46; nurses ix Ghana 43, 156 GHG emissions 187–190, 192, 194, 197; adaptation measures/policies 83, 96, 191, 195–198, 223; carbon footprint 197; emission-mitigation measures/ projects 187, 190–192, 195–197 Global Alliance for Vaccines and Immunizations (GAVI) 10 global care chains 25 global cities viii, 178 Global Compact for Migration x global economy 13, 59, 84, 149 Global Fund to Fight AIDS, Tuberculosis and Malaria 10, 26 Global Health and Migration Corps (GHMC) 23, 217–223, 232–234, 235–237; divisions 221–222; headquarters 221; regional offices 221–222 Global Health Commission of Lancet and University College London 187

Index Global Health Corps (GHC) 134, 217, 223, 237 Global Health Education Consortium 134 Global Health Resource Fund (GHRF) 220 Global Health Workforce Alliance 157 Global Outbreak Alert and Response Network (GOARN) see World Health Organization Global Public Health Intelligence Network (GPHIN) 48 Global Viral Forecasting (GVF) 182 Greece 1, 68–69, 93, 105; 2014 Migration Code 105; Hellenic Red Cross 69 Guantánamo Bay detention center 71, 75; U.S. Central Intelligence Agency physicians and psychologists 71 Guatemala 236–237 Guinea 152, 163, 175–176 habitat alterations 172; see also Ebola Haile Sellassie 219 Haile Sellassie I University 219 Haiti 153, 157; 2010 cholera outbreak 89; 2010 earthquake 84, 214; Ministry of Health 84 Haitians 97 Hajj 24, 39 Harvard Medical International (HMI) 43, 236 health-action plan 122, 213; see also health promotion, action plan health education 39, 49, 113, 132, 155, 204–209, 216, 228 health educators 109 health equity 8, 22, 84, 153, 204, 217–218, 220, 222, 224, 234–235 health lifeboat 2 HealthMap 48, 182 health promotion 11, 15, 19, 49, 110–111, 114, 122, 124, 126, 160, 189, 213, 218, 220, 223, 235, 237; action plan 122, 213; agents 154; trainers 227 health system(s) ix; global 7, 16, 20, 27, 46, 61, 74, 84–85, 95, 128–129, 132, 180, 209, 221, 231; infrastructure 63, 73; internal migration of scarce medical personnel 47; investments 153, 183, 205; migrant-inclusive 132; reform 157; revenue transfer 44, 46–47; strengthening 75, 148, 150–153, 157, 182–183; transnational corporate 48–50; transnational coverage 38; two-tiered 46 healthy-immigrant paradox 109–110

253

Helping Babies Breathe algorithm 237 herd immunity 154 Hickox, Kaci 178, 180 Hispanic epidemiological paradox see healthy-immigrant paradox HIV see HIV/AIDS HIV/AIDS 68, 85, 88, 91, 94, 104–105, 116–117, 124, 153–154, 159, 162, 179, 210, 231–232; see also antiretroviral therapy Hong Kong 2, 152, 183, 197; Vietnamese refugees 68 housing conditions 7, 92, 105, 108, 118, 122, 126, 151–152, 174, 196, 213, 221 human rights viii, xv, 21, 27, 59, 62, 97, 131, 155, 171, 178, 181, 183, 219, 234 Human Rights Watch 82 human smuggling 18, 90; human smugglers xiv, 65, 90, 97; sexual violence 90, 97 human trafficking 18, 90; forced labor and coerced prostitution 91; human traffickers xiv, 87; psychological healing 91 hunger see food insecurity Hurricane Katrina 86 immobility 2, 5, 17, 61, 70, 83 immunization programs 153 India 26, 40–43, 45, 47, 49, 92, 156, 192–193; Apollo Group 49; Delhi 197; nurses 156; Surat 172 Indiana University 209–210 Indiana University-Purdue University, Indianapolis 209–211 Indiana University School of Medicine see AMPATH indigenous-health care 47, 130, 162, 236 indigenous humanitarian organizations 10 indigenous people(s): dam displacement 86; land grabbing 86 industrial accidents 18, 83, 87 influenza 13, 175, 181, 183 Institute of Medicine: Global Health Service Corps recommendation 217 insurance coverage 38–40, 106, 133, 237 intensive-care units 21, 48, 171 intercultural-communication skills/ training 67, 69 (inter)cultural mediators 105, 109, 112, 121, 155 intercultural sensitivity(ies) 207 Intergovernmental Panel on Climate Change (IPCC) 187 internally displaced persons (IDPs) 6, 18, 27, 38, 66–70, 198, 219

254

Index

international agreement on equitable health access 47; see also health systems International Detention Coalition (IDC) 94; Revised Community Assessment and Placement (RCAP) model 94–95 International Development Research Centre see Canada International Diploma in Humanitarian Assistance 223 International Federation of Red Cross and Red Crescent Societies (IFRC) 10, 65, 70, 72, 75, 82, 88, 91; International Committee of the Red Cross 58, 71, 75 international health 6 International Health Regulations (IHR) see World Health Organization International Health Service Corps proposal 217 International Monetary Fund (IMF) 155–156; structural-adjustment conditions 155–156 International Organization for Migration (IOM) 58, 82, 89; Director General William Swing 21; Migration for Development in Africa program 161 International Rescue Committee 10 international trade and finance 59 Internet 10, 40, 50, 115, 119, 153, 159 interpreter(s) 49, 105, 109, 123, 124, 216 interprofessional practice 207, 211 interprofessionals 212 interprofession education 207 Inuit 193 inverse care law 151–152 Iran 67, 197 Iranians 197; Iranian women 134 Iraq 6, 17, 62; Mosul 62–66 Iraqis 66 Ireland 156 Islamic State of Iraq and Syria (ISIS) 17, 26, 60, 62 isolation (wards) 21, 44, 94, 171, 174, 177–178, 180–181 Israel 97 Italy 1, 65, 74, 133; Africa Diaspora Programme 161; Rome 219 Japan 98 Jimma University (Ethiopia) 207 Jing, Chai: Under the Dome documentary 189, 192, 197 Johns Hopkins University: Center for Refugee and Disaster Response, Bloomberg School of Public Health 222

Joint Commission on the Accreditation of Health Care Organizations: Joint Commission International (JCI) 51 Joint U.S.-China Collaboration on Clean Energy 189 Jordan 67, 70 Jordanian Red Crescent Society 70 Kenya 68, 162, 189, 210–211; Dadaab refugee camp 66, 68 Kosovar Albanians 64 Kosovo 64 labor migration ix, 25, 105–106, 157, 196, 205; South-South 25 Lancet Commission on Education of Health Professionals for the 21st Century 27, 222, 238 Lancet Commission on Health and Climate Change (2015) 187 Lancet-University of Oslo Commission on Global Governance for Health (2009) 7, 11, 237; Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health proposal 217 land mines 18 large-scale dam(s) 86 Latin American Medical School (LAMS) 207 lay expertise/wisdom 110, 119 Lebanon 6, 67, 75 Lee, Lia 134 lesbian, gay, bisexual, transgender, and intersex persons (LGBTI) 93–95 Lesotho 38 Liberia 20, 152, 163, 175–176; Airport Authority 178; West Point 177–178 Libya xv, 21, 41, 65, 74, 91 life-style-linked diseases 173 local governments 135, 208 London 41 Madagascar 237 major depressive disorder 98 malaria 39, 67, 152; drug-resistant 173, 183 Malawi 223; Mozambican refugees 68 Malaysia 42–43, 52 Maldives: former President Mohamed Nasheed 194 Male, Ben 148–149 Mali 21 malnourishment 66–67; see also malnutrition

Index malnutrition 13, 18, 46, 63, 66–70, 106, 193; see also malnourishment mammography screening 116 Marburg virus 13, 177 marketing of harmful commodities 84 Mazrui, Ali 87, 131 measles 68, 89 Mecca 39; see also Hajj Médecins du Monde-Greece 133 Médecins Sans Frontières (MSF) 10, 17, 58, 64, 68–69, 75, 82, 88, 91, 93; ethics framework for medical research 21, 209; Goma camps in Zaire 73; Living in Emergency video 97 mediation training 73, 238 medical education 23, 112–113, 158, 204, 206, 210; continuing 112; culturecentered 113; curriculum 160; residency programs 112 Medical Education Partnership Initiative (MEPI) 223 medical interpreters/translators 109, 123 medical interview 110 medical poverty trap 150 medical record(s) 85, 129, 210; loss of 85, 129 medical schools 163, 206–207, 214, 236; see also Indiana University School of Medicine; Johns Hopkins University; Latin American Medical School; Moi University medical students 206, 211, 213, 222 medical-tourism industry 47; accrediting agencies 44, 51; brokers/agents/ facilitators 40, 42, 49, 52, 155; circumvention tourism 51; commercial surrogacy 25; documentation template 44; importation of high-tech medical equipment 49; international trade in medical services 49; legal and financial responsibility 49; oversight committees 44; redistributive-financing mechanisms 44; regulatory challenges 12, 44, 47–48 medical visas 45 Medici Effect 212 medicinal plants 129 Mediterranean Sea: crossing xv, 1, 17–18, 21, 65, 88 mental health/illness 9, 18–19, 24, 27, 66, 69–72, 84–86, 93–96, 106–108, 112, 115–116, 118–119, 122, 129–130, 132–133, 196, 213 Mercy Ships 237 Merlin 88

255

methodological nationalism viii, ix Mexican Americans 38, 109–110 Mexican migrants 25, 90, 97, 105–106, 129, 173 Mexico xi, xiv, 38, 107, 134, 163, 183, 236; 2017 earthquakes 96; Central American migrants 27, 90, 134; hospitals mixtos (mixed hospitals) 155; Oaxaca 155; Puebla 107; San Francisco Xochiteopan 97 microbiologists 175 Middle East xv, 26, 45, 66, 236 Middle East respiratory syndrome (MERS) 13; see also ERIDs migrant-friendly hospital(s) 132 migrant workers 24, 38, 82, 105–106 “migration management” 74; efforts to externalize migration controls xv, 90 military protection for humanitarian operations 65 Millennium Development Goals (MDGs) 158 Millennium Villages project 154 mini ethnography see ethnography ministries 208, 220 mobile clinics 75 mobile devices 130, 153 mobile health through text messaging (mHealth) 49, 129 Moi University 210; Moi University School of Medicine 209–211; see also AMPATH Montana 219, 236; Missoula 218 Moore, Michael see Sicko “motility” competence 96 Mozambique 38, 62, 198 multilevel advocacy 134 multi-local lives 130 multinational corporations 49, 59; see also private firms multisited ethnography see ethnography Myanmar 18, 46, 61, 70, 74, 97; Rakhine State 68 Nansen Initiative 92 natural disasters xi, 83–84, 87 negative-pressure (isolation) hospital rooms 181 neglected tropical diseases (NDTs) 163 network capital 4, 24 Network of Ethiopian Professionals in the Diaspora 164 Nevada 219 New Jersey 97

Health challenges for refugees

59

The roots of many contemporary migrant-generating conflicts can be traced to North-South political dynamics (Samers and Collyer, 2017, p. 3; GarciaZamora, 2017, p. 591). By shaping the political-economic triggers of armed conflict and persecution, transnational institutional conditions both constrain and facilitate population movement. Key features of the global economy, particularly unequal terms of international trade and finance, penetration by multinational corporations, and the hegemonic influence of certain multinational gatekeepers, undermine healthy lifestyles (Jacobs and Richtel, 2017) and foreclose sustainable development in much of the Global South. Commitment to neo-liberal principles under the Washington Consensus sustained Northern exploitation of Southern economies, a process expanded by the post-Washington Consensus to involve the imposition of sweeping conditionalities under the umbrella of “good governance” (Fine and Saad-Filho, 2014). Global and domestic economic inequities and resulting hardships, in turn, prod threatened regimes to stifle opposition through political persecution, human-rights violations, and the application of systematic violence (Toole, 2006, p. 190; Ottersen, 2014). Oppressive regime actions and reactions help to ignite spiraling civil strife. Venezuela provides one contemporary case in point (see Box 2.1; Benzaquen, 2017). Multinational institutions, meanwhile, have proven ineffective in mitigating the volatile underlying mix of domestic disparities and “external disruptors” that catalyze armed conflicts in the South (Ottersen, 2014, p. 653; Koehn, 1991).

Box 2.1 Venezuela’s Cruz Verde responds to protest injuries A teenage boy lay on the ground after a clash with the police. “Medico, medico!” a young man screamed through the thick fog of tear gas at a protest in Caracas, Venezuela. The medics he was calling for, known as the Cruz Verde or Green Cross, have become a regular fixture at violent clashes between opposition protesters and government forces. At least 90 people have died since the demonstrations began in April. . . . Video showed Green Cross volunteers crowding around the injured teenager, Neomar Lander, 17, and carrying him out of the worst of the fighting. Mr. Lander later died. But group organizers say they treat dozens of patients daily, and believe that the first aid they deliver has been crucial in saving lives. The Venezuelan economy’s near-collapse has devastated medical facilities and supply lines, and limited state-run emergency care at demonstrations, according to the group. . . . Many of the volunteers are students in their 20s. Dozens of qualified doctors have also joined their ranks, which number around 200 in Caracas. They have similar affiliated groups that attend protests around the country.

Index record keeping, cross-border 154 Red Cross and Red Crescent see International Federation of Red Cross and Red Crescent Societies Refugee Convention of 1951 198 Regional Network for Equity in Health in East and Southern Africa (EQUINET) 153 relocation xii, 72, 85, 92, 96, 191, 196, 198; see also resettlement schemes remittances: economic 20, 27, 97, 158–159, 196; social 20 repatriation 20, 38, 67, 154–156, 160; medical treatment 72, 155; training programs 72, 155 resettlement schemes 22, 87, 92, 191, 196 resilience 16, 23, 84, 89–90, 95, 107, 119–121, 132, 153, 196 reskilling 21; see also brain waste; deskilling returned refugees see repatriation return migration see repatriation reverse innovation 23, 160, 222, 231 Revised Community Assessment and Placement model 94–95 Rohingya 18, 68, 70, 74, 97 Roll Back Malaria Partnership 163 Russia 41 Rwanda 43, 61, 63, 73, 97, 148, 161, 223 Sahrawi 158 Salvadorans 133 sanctuary cities 10 San Diego Refugee Health Services Consortium 111 sanitation 70–71, 73, 75, 85, 89, 93, 151–152, 174, 221, 237 Saudi Arabia 17, 64, 97, 219; nurses and doctors 156 Save the Children 69–70, 88 scaling out/up 216 scientific research 208 SDGs see sustainable-development sea-level rise 22, 84, 86, 188, 190–191, 193–194; coastal megacities 191, 193; delta areas 193 securitization 13, 19, 93, 181–182; security-sector forces 181 security agenda 176; security threat(s) 13, 176, 181 Sen, Amartya 233 severe acute respiratory syndrome (SARS) 2, 25, 52, 152, 173–177, 183, 190; coronavirus 175 sexual abuse/exploitation 91, 94, 224

257

sexual transmission 63, 90–91, 116–117, 134, 173 Shanghai 46, 86, 191 Sheffield University 149 short-term medical missions/service 23, 213–217, 222 Siberia 190 Sicko 51 Sierra Leone 64–65, 152, 163, 180; Makeni 174 Sightsavers 149 Singapore 42, 51–52, 214 small-island states 194 smartphones see mobile devices Smith, Luke 107 smoking 9, 110, 112 social capital 209, 227; transnational 50, 161, 235 social exclusion 21; canceling mass gatherings 182; closing schools 182 social media 10, 15 social mobility: downward 116; upward 116 Society of General Internal Medicine Health Disparities: Task Force 115 sociophysiologic feedback 121 Somalia 63, 65, 69; Al Shabaab 74; Mogadishu 70; shade tax 97 Somali diaspora community in UK 46 Somali health-care practices 130 Somali IDPs: Afgoye corridor 70 Somaliland 74; Center for International Humanitarian Cooperation (CIHC) 74; Hargeisa 73–74 Somali migrants 66, 68, 74 South Africa 26, 38, 41–43, 45, 52, 162, 208 South America xi South Korea 43; Jeju Healthcare Town 43 South Sudan 61, 63, 74 South Sudan migrants 74 Spain 133, 158; Secretary of State for Security José Antonio Nieto 87 Sphere Project 69, 75, 97; Humanitarian Charter 69, 88 stakeholder participation 216 stem-cell treatments 41 stigma 108, 233; stigmatization 132, 175, 178, 182 storm surge(s) 191, 194 structural-adjustment programs see International Monetary Fund Sub-Saharan Africa see Africa subsidence 86, 191, 194 Sudan 67, 74, 157, 219 Sudanese migrants 97

258

Index

support networks 83, 126, 178; rupture of 85, 118 surface-structure communication 124 surgical tourism see short-term medical missions surveillance: capacity 13; digitalsurveillance technologies 182; early warning 91, 179, 198; failures 175; outbreak-alert systems 13; passive 176; rapid-response mechanisms 13; rapidverification procedures 179 sustainable development i, xii, 2, 11, 16, 20, 59, 89, 92, 133, 148–155, 158–159, 162–164, 173, 183, 192, 196; goals (SDGs) and targets xii, 20, 152, 158 Sustainable Development Summit, 2015 158 Sweden 27 Switzerland ix, 92, 190 syndemics analysis 90 Syria 17, 25, 61, 63–64, 71; Damascus; IDPs 6, 67; Iraqi refugees 66; prisons 71; Qaryatayn 74 Syrian refugees 66–67, 75 Taiwan 42, 163; Taipei 152 Taiwanese 163 Tanzania 75, 96, 148 Tanzanians 75 task shifting, task-shifting initiatives 20, 148, 152, 157, 163, 205, 220 telehealth collaborations 50, 128 tele-medicine 115, 119, 129, 153, 161, 212; “reverse” tele-medicine 125; tele-diagnosis 128; see also telehealth collaborations terrorism/terrorists 19, 60; captive-terroristsuspect torture 90; see also bioterrorism; Guantánamo Bay detention center; Islamic State of Iraq and Syria Thai International Health Policy Programme 236 Thailand 40–43, 47, 51; Bumrungrad International Hospital 49; Cambodian refugees 68; fishing vessels 82; Songkhla Province 97 therapeutic alliance 125, 127, 132 therapist blinders 107 thermal scans 176 think tanks 208 tobacco companies 10 Togo 155, 215–217, 221; Farendé 215; Kabre’s local medical system 215; Lomé 215 Tokushukai Medical Corporation 41 Toronto 152

trade xiv–xv, 13, 20, 26, 49, 59, 148, 172; embargoes 179 traditional healers see traditional medicine traditional medicine 42, 129, 155; see also alternative therapies; traditional healers training of trainers 231 Transfer of Knowledge through Expatriate Nationals programme (TOKTEN) 161 transnational adoptions 25 transnational corporations see multinational corporations transnational disorders 154 transnational higher-education partnerships (THEPs) 208–211, 228–232 transnational protest movements viii transplants 16, 41, 43, 48 travel illness 39 travel medicine 39 triage 181 tropical regions 171–172 Trump, Donald: candidate 173, 179–180, 183 tuberculosis (TB) 134, 153, 174 Turkey xv, 1, 67 Udofia, Mfoniso 15 Uganda 73, 148–149, 156, 223; Greenwich/Makerere experience 236 Ugandans 148, 150 UNAIDS (Joint United Nations Programme on HIV/AIDS) 163 undernourishment 151; see also malnourishment undocumented migrants 25, 90, 106, 129, 133 unfinished endings 116 U.N. High Commissioner for Human Rights 74 U.N. High Commission for Refugees (UNHCR) 6, 10, 18, 58, 62, 67–68, 70–72, 74, 82, 88, 94, 98, 206; 2016 Global Trends Report 58; “people of concern” 18, 58, 66, 74 UNICEF 219 United Arab Emirates 43; investors 43 United Kingdom (UK) xvii, 43, 45, 109; NHS staff ix; Volunteer Service Overseas programme 164 United Nations (UN) 10; agencies 11; Emergency Relief Coordinator 89; Global Compacts on Safe, Orderly and Regular Migration and on Refugees, 2018 xii; High Level Dialogue on Migration and Development, 2006 xi; Multistakeholder Platform on Global Governance for Health (proposed)

Index 25; New York Declaration, 2016 xi; peacekeeping forces 58, 89; Report on Prevention and Control of Noncommunicable Diseases 151; SecretaryGeneral Ban Ki-moon 94; Security Council xv; Sendai Framework for Disaster Risk Reduction 2015–2030 95 United Nations Development Programme (UNDP) 58, 188; Transfer of Knowledge through Expatriate Nationals (TOKTEN) program 161 United Nations Environmental Programme (UNEP) 188 United Nations Framework Convention on Climate Change see Paris Agreement adopted at the Conference of Parties to the United Nations Framework Convention on Climate Change United Nations Office for Disaster Risk Reduction (UNISDR) 96 United States (USA) viii, xi, xii, xvi, 5, 13, 19, 25–26, 42–43, 45, 51, 75, 97, 104, 106–107, 109–110, 129, 130, 133, 155, 164, 179–180, 183, 190, 192, 194, 197, 210, 214, 222; Affordable Health Care Act 106, 133; Border Patrol xiv; border states with Mexico 90; decennial census 107; detention centers 71; emergency-medical care 106; healthcare workers 156; immigrant physicians 20, 156; immigration reform, 1965 xiv; Medicaid 106; northeastern USA 223; southern America 173; U.S.-Mexico border 27, 134, 173 universal (health) coverage 132 Universal Declaration of Human Rights xv, 178; Article 25 89 University of Alabama at Birmingham 231 University of Calgary 236 University of KwaZulu-Natal 208 University of Montana i, 24–25, 219, 236 University of Toronto: Bio.Diaspora project 182 University of Washington team 97 U.N. Office on Drugs and Crime (UNODC) 97 vaccinations 39; vaccination campaigns 237 vaccines 171, 181, 183; influenza A strains 183; manufacturing 180–181; production and distribution 21, 171

259

Venezuela 59; Cruz Verde or Green Cross 59–60 ventilators 21, 171, 181 Vietnam 46, 157, 183 Vietnamese refugees see Hong Kong village health centers 154 VillageReach 153 virologists 175 voluntourism 213–214 walls (border) 131, 177, 183 Washington, D.C. 219 Washington Consensus 59; post-Washington Consensus 59; see also global economy web-based resources 40, 134 wellness practices 23, 51, 108, 125, 192, 221 West Nile virus 173 WhatsApp 12, 83, 129 World Bank 26, 149, 220; Africa Diaspora Programme 163; President Jim Yong Kim 183; see also Global Health Resource Fund World Economic Summit (2017) 190 World Health Organization (WHO) ix, 10–13, 17, 26, 44, 64, 96, 131, 163, 175–176, 179, 188, 205, 231, 235; 2010 Global Code of Practice on the International Recruitment of Health Personnel 157; 2010 Global Consultation Report 24; administrative reforms 183; budget 11, 26, 183; Commission on Social Determinants of Health 22, 223, 238; Constitution xvi, 72, 135; Director-General Tedros Adhanom Ghebreyesus 11; Global Outbreak Alert and Response Network (GOARN) 48; International Health Regulations (IHR) 21, 52, 171, 175 World War II xiv xenophobia xi, 71, 131 Yazidi women 62 Yemen 17, 64–65; Abs Hospital 64 Yugoslavia 155 Zambia 157, 223, 231 Zika virus 85, 173 Zimbabwe 38, 89, 158 zoonoses 172; zoonotic transmissions 21, 171–172