Sunday, September 21, 2008

18th September 2008, Stockholm
To the
European Centre for Disease Prevention and Control. This was my first visit to ECDC, although we do work closely with colleagues there, most recently in our new book on the health system response to complex communicable diseases (primarily, but not only, HIV and TB). Unusually, this time we looked beyond Europe, drawing lessons from both Europe and another region undergoing political and economic transition, Latin America and the Caribbean.
I was there as a member of an expert advisory group on migration. The 2007 Portuguese EU presidency placed the health aspects of migration on the policy agenda and the ECDC is in the process of preparing a report on its consequences for communicable disease.
In some countries, in particular the UK, migration has become a highly politicised issue. Even though the UK has benefited enormously from migration (whether as assessed by the number of foreign born “British” Nobel Prize winners or the army of unrecognised workers who care for the elderly and disabled in our society), there are still shrill voices calling for ever tighter restrictions. These calls have, regrettably, been heard by the current government which has put in place a draconian process to limit the number of highly skilled migrants, as well as quite disgraceful treatment of asylum seekers fleeing persecution in other parts of the world. It has come under particular criticism for its inhumane treatment of children in families seeking asylum. These points are worth recalling as it is easy to overlook the reality that the major threats that migration poses to health are to the health of the migrants themselves.
The report is due out at the end of the year. It will focus on three areas, TB, HIV, and vaccine-preventable disease. However, what became clear from our discussions was the need for an extensive preamble, defining and categorising different types of migration and providing a conceptual framework to understand the health consequences of migration.
A major challenge will be collecting the necessary data. In part reflecting differences in laws on citizenship (at the risk of over-generalisation, there are two approaches – jus solis , where citizenship depends on where you were born, and jus sanguis, where citizenship depends on the nationality of your parents) and constraints arising from data protection legislation.
At the end of our meeting I gave a lecture on migration and health, entitled threats and opportunities. You can see a
short video on the ECDC website. It was an opportunity to recall that, even after the breaking down of barriers in Europe in 1989-91, we still live in a divided continent, inhabited by young and old and native-born and migrants. The European social system is, however, based firmly on solidarity. This solidarity owes much to the experiences of the 1940s, where even the most wealthy could be reduced to ruin when they became caught up in the conflict. Two recent books remind us that people of all nationalities suffered. These are Norman Davies’ Europe at War (in which he once again reminds us of the extent of Europe, in this case recalling the carnage on the Eastern Front), and Giles MacDonogh’s After the Reich (where he describes the horrors of the retributions visited on Germans after May 1945). The knowledge that you could go to bed rich but wake up poor ensured that the generation that survived would put in place arrangements to protect their fellow citizens from the consequences of illness and unemployment. This contrasts with the the USA, which has never managed to achieve universal health care coverage. There, those in power, who were overwhelmingly white, could be confident that they would never wake up black. The question we must face up to is whether our belief in solidarity is strong enough to survive the pressures of aging populations, increased migration (by those who are visibly different) and economic downturns. Unfortunately there are some worrying signs in many countries, with growth of extreme xenophobic parties. As Martin Niemoller reminded us over 60 years agoin his famous poem (First they came for...), this challenges everyone who believes in solidarity to speak out before it is too late.

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