Kolitha Wickramage, Lawrence O. Gostin, Eric Friedman, Phusit Prakongsai, Rapeepong Suphanchaimat, Charles Hui, Patrick Duigan, Eliana Barragan, and David R. Harper
Influenza pandemics are perennial global health security threats, with novel and seasonal influenza affecting a large proportion of the world’s population, causing enormous economic and social destruction. Novel viruses such as influenza A(H7N9) continue to emerge, posing zoonotic and potential pandemic threats. Many countries have developed pandemic influenza preparedness plans (PIPPs) aimed at guiding actions and investments to respond to such outbreak events.
Migrant and mobile population groups—such as migrant workers, cross-border frontier workers, refugees, asylum seekers, and other non-citizen categories residing within national boundaries—may be disproportionately affected in the event of health emergencies, with irregular/undocumented migrants experiencing even greater vulnerabilities. Because of a combination of political, sociocultural, economic, and legal barriers, many migrants have limited access to and awareness of health and welfare services, as well as their legal rights. The conditions in which migrants travel, live, and work often carry exceptional risks to their physical and mental well-being. Even if certain migrant groups have access to health services, they tend to avoid them due to fear of deportation, xenophobic and discriminatory attitudes within society, and other linguistic, cultural, and economic barriers. Evidence indicates that social stigmatization and anxieties generated by restrictive immigration policies hinder undocumented immigrants’ access to health rights and minimizes immigrants’ sense of entitlement to such rights.
Migrant inclusivity in PIPPs
PIPPs that are migrant inclusive and mobility competent enable greater public health protection for all. The majority of human cases of influenza A (H5N1) infection have been associated with direct or indirect contact with infected live or dead poultry. Worldwide, migrant workers are overrepresented in sectors such as poultry farming and related industries. If they are not reached by disease prevention services or surveillance systems, and if they are reluctant to seek public health services, they may constitute a high-risk population for pandemic influenza. Migrant workers also represent a possible “bridge population” for viral spread—defined as a population transmitting infection from a high-prevalence group to individuals who would otherwise be at low risk of infection—when they travel to their place of origin. It is thus imperative to understand the linkages between formal and informal migration routes with networks of migrant labor in animal husbandry and related industries for instance in order, to develop evidence-based policies that anticipate and prevent the emergence of novel zoonosis.
In 2017, an estimated 258 million people—including 26 million refugees and asylum seekers—lived in a country other than their country of birth, representing an increase of 49% since 2000. The Asia-Pacific region housed the majority of these international migrants (80 million) and remains the leading region of destination for international migrants, with 106 million inflows in 2017. This region, which houses 17 of the world’s 31 mega cities, also has some of the world’s largest and most diverse migration corridors from the Global South to the Global North, as well as across countries of the Global South.
We sought to explore the extent to which migrant and mobile population groups have been included in national PIPPs for selected countries within the Asia-Pacific region. We obtained PIPPs from official government sources (namely, ministries of health) that were available at the time of review (between January and June 2016). Twenty-one countries were randomly selected based on the World Bank’s classification of low- to middle-income countries. A framework analysis of each PIPP was undertaken by two of this paper’s authors, who independently reviewed each plan to identify the extent to which it described migration and mobility dynamics. A data-abstraction instrument was designed based on key search terms.
We found only three countries (Thailand, Papua New Guinea, and the Maldives) that identified at least one migrant group within their respective national plans (see Annex 1). Furthermore, we found that most countries (18 of 21) specified health control measures along their borders, such as point-of-entry screening strategies for inbound travelers.
Papua New Guinea’s plan identifies the potential for “stigma and discrimination” against West Papuan refugees carrying avian influenza, as well as the possible psychosocial and economic impact of public health measures on such individuals. The PIPP outlines coordination measures among community health and welfare service providers to support displaced populations and refugees. Meanwhile, Thailand undertook a comprehensive assessment of its previous PIPP and found that the plan was “incongruent” with the current health situation of migrant workers, internally displaced persons, and individuals within mobility corridors in cross-border areas. Thus, its new PIPP has been formulated as part of a broader national strategy for emerging infectious diseases that goes beyond viral flu to integrate a “one health” approach. The new plan makes specific reference to and designs strategies for rural and urban migrants and temporary migrant workers crossing international boundaries. It recognizes that such groups are at higher risk due to their limited access to health information, which leaves them with insufficient knowledge on how to prevent infectious diseases. Finally, the Maldives identifies “non-citizen expatriate workers” as a priority group within its PIPP and provides strategies for addressing shocks within the health system stemming from migration.
To comply with international human rights law, states should provide essential health services, especially disease prevention services, to migrants as well as their own nationals. However, many have explicitly stated before international human rights bodies and in domestic legal frameworks that they cannot, or do not wish to, provide migrant groups with the same level of protection that they offer their own citizens.
Despite the particular barriers they face, vulnerable groups within PIPPs are often presented as a homogeneous subpopulation. A World Health Organization review of PIPPs in 2011 showed that only 13 of 119 countries (11%) had strategies to address the communication needs of minority groups (defined as ethnic minorities, refugees, immigrants, and indigenous peoples). The invisibility of some migrant and mobile population groups is not surprising given that cultural identities are often ignored in the focus on these groups’ political, legal, and economic status. The World Health Organization’s Asia-Pacific Strategy for Emerging Diseases and Public Health Emergencies (2017) emphasizes a focus on “gender, equity and human rights” in the development of national public health capacities, though it falls short of providing specific recommendations regarding vulnerable groups and on migrant inclusion. States’ obligations under the right to health extend to all inhabitants and are not limited to citizens and lawful residents. The strategic framework makes specific calls for “individual citizens” to identify and report unusual or unexpected events but falls short of outlining aspects for non-citizens such as irregular migrant workers at poultry farms, who may be at increased risk. As previously highlighted in this Journal, the scope of protection and effectiveness of global health frameworks in guaranteeing health protection for non-nationals remains unclear and elusive.
Asylum seekers, itinerant migrant workers, and other undocumented migrants are often exposed to high-risk working and living environments, yet they remain marginalized within national health systems. As reflected in the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families, adopted by the United Nations General Assembly in 1990, their protections are limited to “life-saving” and “emergency” medical services. Some states, such as those within Europe are making efforts to ensure more equal access to migrants and offer a greater range of health services—from primary to reproductive health care—irrespective of legal status. However, wide disparities in entitlements across irregular migrant groups remain.
Work is a principle driver of human mobility. The majority (65%) of international migrants are workers who actively participate in the labor force of destination countries. Ensuring the right to health for migrants also requires states to ensure occupational health and a safe working environment. International Labour Organization Conventions 155 and 161, the United Nations Guiding Principles on Business and Human Rights, the United Nations Resolution on the Protection of Migrants, and the Sustainable Development Goal 8 on “decent work and economic growth” all called upon governments to protect rights of migrant workers.
During major disease outbreaks and health emergencies, such as the West African Ebola epidemic in 2014, migrants may also be unfairly discriminated against, be perceived as vectors of disease, and have their travel restricted. In times of health emergencies where resources and vaccines are in demand, provision to vulnerable groups may also be contested. Politicization and factors such as “othering” may prompt non-evidence-informed decision making. Human rights concerns need to support the prioritization of vulnerable and stigmatized groups for vaccination during a pandemic.
Migration governance rests upon the fulcrum of national sovereignty, whereas pandemics and other novel diseases transcend local, national, and regional boundaries. Migration is framed by general international law, where the human rights of all people, including migrants, are an integral part of public international law. The legally binding nature of the right to health and its principle of non-discrimination remain key underpinnings to advocating for non-nationals’ access to health care. The Committee on Economic, Social and Cultural Rights is clear that migrants of all stripes, “regardless of legal status and documentation,” shall be ensured their rights in full. In essence, global health security should be expanded to include global health solidarity. In reiterating the call of the Sustainable Development Goals to “leave no one behind” and to address global health security in a meaningful way, we contend that irrespective of a person’s migrant status, his or her access to health services and social protection must be included within pandemic preparedness and response efforts.
Kolitha Wickramage, PhD, is the head of Migration Health Research and Epidemiology, Migration Health Division, the International Organization for Migration, the United Nations Migration Agency, Geneva, Switzerland.
Lawrence O. Gostin, JD, is professor of Global Health Law; Faculty Director, O’Neill Institute for National & Global Health Law; Director, World Health Organization Collaborating Center on Public Health Law & Human Rights, University Professor at Georgetown University, Washington, DC, USA.
Eric Friedman, JD, is project leader, Platform for a Framework Convention on Global Health (FCGH) at the O’Neill Institute for National and Global Health Law Georgetown University, Washington, DC, USA.
Phusit Prakongsai, PhD, is the senior advisor on health promotion, Office of Permanent Secretary, Ministry of Public Health of Thailand, Nonthaburi, Thailand.
Rapeepong Suphanchaimat, PhD, is a researcher at the Bureau of Epidemiology, Department of Disease Control, and the International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand.
Charles Hui, MD, is chief of infectious diseases at the Department of Pediatrics, University of Ottawa, and chair of the Migration Health and Development Research Initiative, Faculty of Medicine, University of Ottawa, Canada.
Patrick Duigan, MD, is the regional migration health thematic specialist at the International Organization for Migration’s Regional Office for Asia and the Pacific, Bangkok, Thailand.
Eliana Barragan, MA, is the migration health programme officer at the International Organization for Migration, Geneva, Switzerland.
David R. Harper, PhD, is a senior consulting fellow at the Centre on Global Health Security, Chatham House, London, UK.
Please address correspondence to Kolitha Wickramage. Email: firstname.lastname@example.org.
Competing interests: None declared.
Copyright © 2018 Wickramage, Gostin, Friedman, Prakongsai, Suphanchaimat, Hui, Duigan, Barragan, and Harper. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
Table 1. Analysis of PIPPs from 21 low- to middle-income countries in the Asia-Pacific region
publication date of PIPP
|WHO region*||Migrant and mobile population groups defined within PIPP?||Border control measures?**||Cross-border animal health measures?***|
|Papua New Guinea
* SEAR (South East Asian Region); WPR (Western Pacific Region)
** For example, point-of-entry screening and health information for travelers at airports, seaports, and land crossings
*** Strategies to prevent avian influenza transmission via migratory bird populations and the importation of poultry
Methodology: We sought to examine the extent to which migrants and mobile populations are included in pandemic preparedness plans (PIPPs) for selected countries within the Asia-Pacific region. A total of 48 countries from this region (according to the World Health Organization’s classification) were listed, and 21 countries were randomly selected using a random number table. Two authors reviewed each PIPP using a data-reduction instrument. The documents were analyzed for content and meaning, as well as through key-word searches from a list of terms describing migrants and mobile population groups and cross-border measures (Table 2). An open-source web-based software application entitled Voyant tool (https://voyant-tools.org) was used to undertake the document analysis per search strings listed in Table 2.
Table 2. Example of key words searched
|Domain||Key words searched|
|Migrants and mobile population groups:|
|(*migrant* OR transient* OR *migrat* OR overseas OR “cross-border” OR non-citizen* OR non-national* OR “domestic maid*”) AND (worker OR workforce OR laborer OR labourer OR gardener OR farmworker OR “farm-worker*” OR industr* OR poultry OR agriculture OR “high skilled” OR “low-skilled” OR driver) OR (“internat* *migrant worker*” OR “foreign home care worker*” OR “foreign domestic worker*” OR “foreign domestic helper*” OR “transnational domestic worker*” OR “foreign domestic employee*” OR “overseas domestic worker*” OR “domestic migrant worker*” OR “International Labour migrants” OR “internat* illegal *migrant*” OR “Temporary migrant worker” OR “migrant health worker*” OR “frontier migrant worker” OR “Expatriate workers” OR “Inbound *migrant* worker*” OR “irregular *migrant” OR “irregular migration” OR “irregular *migrant*” OR “labour migration” OR “labor migration”) OR non-national migrant worker OR non-citizen migrant worker OR “intra-regional migrant” OR consular OR military OR diplomat* OR “international health elective*” OR “internal migration” “international *migrant*” OR “international *migration”)|
|International students||“international student*” OR “foreign student*”|
|Refugees, asylum seekers||refugee* OR “asylum seek*” OR “displaced person*” “forced migrants” OR ” displaced people” OR “stateless person” OR “exile” OR “uprooted person” OR “asylum process” OR “Asylum – seek*”|
|Trafficking victims, victims of human smuggling||traffick* OR smuggl* human OR woman OR child* OR sex OR prostitute* OR girl* OR *migrant* “forced labour” OR “forced labor” OR “forced prostitution” OR “sexual slavery”|
|Patient mobility across borders||mobility OR movement OR transfer OR smuggl*) AND (patient* OR ill OR sick) AND (border* ) OR (“patient* *migrat*”)|
|Cross-border measures||International points of entry OR Points of entry OR Ports OR Airport OR Seaport OR Land crossings OR Ground crossings OR Cross-border OR Entry/Exit point OR International boundaries OR International crossings OR Foreign borders OR Border control OR Immigration control.|
|Cross-border animal health measures||Birds OR poultry OR wild birds OR wild duck OR Chicken OR Chicken farms OR poultry farms OR poultry markets OR migratory birds|
Table 3. Example of a country-level summary
|Country||Title of PIPP||Migrant and mobile populations cited||Border control measures|
|Papua New Guinea||National Contingency Plan for Preparedness and Response for Influenza Pandemic (2006)||The objective of the plan is to “prevent the spread of avian influenza virus from its native host (wild birds) into and amongst domestic poultry or other non-native species, including humans.” The plan makes specific reference to refugee and displaced populations (for instance, West Papuan refugees and the psychosocial and economic impact of public health measures on these groups). It calls for close collaboration with health and other welfare service providers, and the provision of support to internally displaced populations and refugees.||Relevant actions stipulated in PIPP addressing human mobility:
Section 1.6 includes a review of public health legislation to ensure the legal mandate for emergency powers, social distancing, border controls, quarantine, and adherence with International Health Regulations (2005) for public health events of international concern. Enhanced measures at ports of entry are also stipulated for all inbound flows. The plan also calls for monitoring the import of bird products (such as dried meat and feathers) that could potentially spread the bird flu.
 M.A. Widdowson, J.S. Bresee, and D. B. Jernigan. “The Global Threat of Animal Influenza Viruses of Zoonotic Concern: Then and Now,” The Journal of Infectious Diseases 216 (suppl 4), (2017) pp. S493-S498.
 World Health Organization. Comparative analysis of national pandemic influenza preparedness plans. (Geneva, WHO Publications, 2011).
 World Health Organization. Beyond the barriers: framing evidence on health system strengthening to improve the health of migrants experiencing poverty and social exclusion (Geneva, WHO Publications, 2017).
 International Organization for Migration, World Health Organization, Office of the High Commissioner for Human Rights, International migration, health and human rights (Geneva, IOM Publications, 2013).
 S. Larchanché “Intangible obstacles: health implications of stigmatization, structural violence, and fear among undocumented immigrants in France,” Social Science & Medicine, 74(6), (2012) pp.858-863; O. Martinez, E. Wu, T. Sandfort, B. Dodge, A. Carballo-Dieguez, R. Pinto, S. Rhodes, E. Moya, S. Chavez-Baray.. “Evaluating the impact of immigration policies on health status among undocumented immigrants: a systematic review,” Journal of Immigrant and Minority Health. Jun 1;17(3) (2015) pp. 947-70.
 K. Ungchusak,, P. Sawanpanyalert, W. Hanchoworakul, N. Sawanpanyalert, S.A. Maloney, R.C. Brown, M. E. Birmingham, and S. Chusuttiwat. “Lessons learned from influenza A (H1N1) pdm09 pandemic response in Thailand,” Emerging infectious diseases. (2012) 18(7); I. Piller & L. Lising. “Language, employment, and settlement: Temporary meat workers in Australia,” Multilingua. 33(1-2), (2014) pp. 35-59; M. Sargeant & E. Tucker. “Layers of vulnerability in occupational safety and health for migrant workers: case studies from Canada and the UK,” Policy and practice in health and safety 7(2), (2009) pp. 51-73; E. Kyerematen-Amoah, J. Nowell, A. Lutty, P. S. Lees & E. K. Silbergeld, “Laceration injuries and infections among workers in the poultry processing and pork meatpacking industries. American journal of industrial medicine,” 57(6), (2014) pp. 669-682; A.L. Steege, S. Baron, S. Davis, J. Torres-Kilgore, & M.H. Sweeney. “Pandemic influenza and farmworkers: the effects of employment, social, and economic factors,”. American Journal of Public Health. 99(S2), (2009) pp. S308-S315.
 UNAIDS Terminology guidelines, revised version (Geneva, UNAIDS 2011).
 J. Otte, D. Roland-Holst, D. Pfeiffer, R. Soares-Magalhaes, J. Rushton, J. Graham, and E. Silbergeld. “Industrial livestock production and global health risks.” Food and Agriculture Organization of the United Nations, Pro-Poor Livestock Policy Initiative Research Report (2007).
 United Nations Department of Social and Economic Affairs, The international migration report 2017 (highlights) (New York: UNDESA, 2017). Available at https://www.un.org/development/desa/en/news/population/international-migration-report-2017.html.
 Ungchusak et al. (see note 6).
 L. Thompson, “Protection of migrants’ rights and state sovereignty,” UN Chronicle L/3 (2013); International Organization for Migration et al. (see note 4).
 J. P. Garoon and P.S. Duggan. “Discourses of disease, discourses of disadvantage: a critical analysis of National Pandemic Influenza Preparedness Plans,” Social Science & Medicine 67(7), (2008) pp.1133-1142.
 World Health Organization (see note 2).
 L. O. Gostin and B. E. Berkman, “Pandemic influenza: Ethics, law, and the public’s health,” Administrative Law Review 59 (2007), p. 121; E. Gilbert, “Leaky borders and solid citizens: Governing security, prosperity and quality of life in a North American partnership,” Antipode 39/1 (2007), pp. 77–98.
 World Health Organization, Asia Pacific strategy for emerging diseases and public health emergencies (APSED III): Advancing implementation of the International Health Regulations (2005); Working together towards health security (Geneva: WHO, 2017).
 C. Lougarre. “Using the Right to Health to Promote Universal Health Coverage: A Better Tool for Protecting Non-Nationals’ Access to Affordable Health Care?” Health and Human Rights. 18/2, (2016), p.35.
 International Organization for Migration et al. (see note 4).
 S. Spencer and V. Hughes, “Outside and in: Legal entitlements to health care and education for migrants with irregular status in Europe” (2015). Available at https://www.compas.ox.ac.uk/2015/outside-and-in.
 M. A. Flynn and K. Wickramage, “Leveraging the domain of work to improve migrant health,” International Journal of Environmental Research and Public Health 14/10 (2017), p.1248.
 Office of the United Nations High Commissioner for Human Rights, Guiding principles on business and human rights: Implementing the United Nations “protect, respect and remedy” framework (New York: United Nations, 2011); International Labour Organization, Occupational Safety and Health Convention, 1981 (No. 155); International Labour Organization, Occupational Health Services Convention, 1985 (No. 161); United Nations General Assembly, Resolution 69/167, UN Doc. A/RES/69/167 (2014); United Nations, Sustainable Development Goals. Available at http://www.un.org/sustainabledevelopment/sustainable-development-goals.
 D. L. Heymann, L. Chen, K. Takemi, et al., “Global health security: The wider lessons from the west African Ebola virus disease epidemic,” Lancet 385/9980 (2015), pp. 1884–1901.
 N. J. Grove and A. B. Zwi, “Our health and theirs: Forced migration, othering, and public health,” Social Science and Medicine 62/8 (2006), pp. 1931–1942.
 C. Kaposy and N. Bandrauk, “Prioritizing vaccine access for vulnerable but stigmatized groups,” Public Health Ethics 5/3 (2012), pp. 283–295.
 V. Chetail, “The human rights of migrants in general international law: From minimum standards to fundamental rights,” Migrants and Rights 15 (2017) pp. 3–34.
 Lougarre (see note 18).
 Committee on Economic, Social and Cultural Rights, General Comment No. 20, Non-discrimination in Economic, Social and Cultural Rights UN Doc. E/C.12/GC/20 (2009).
 A. Flahault, D. Wernli, P. Zylberman, and M. Tanner, “From global health security to global health solidarity, security and sustainability,” Bulletin of the World Health Organization 94/12 (2016), p. 863.