J ChronDis 1975, Vol. 28, pp. 579-592. Pergamon Press. Printed in Great Britain
SOME ISSUES ASSOCIATED WITH MIGRATION, HEALTH STATUS AND THE USE OF HEALTH SERVICES* JOHN B. MCKINLAY Department
of Sociology, Boston University and Massachusetts (Primary Care Unit), Boston, Massachusetts
General Hospital
(Received in revised form 4 February 1975)
Abstract-In comparison with other areas of Medical Sociology, the study of the various effects of migration on health and health-related behavior has remained largely unexplored, despite the magnitude of the processes involved and the fact that migration now probably constitutes the most important vehicle of social change confronting any society. This paper attempts to accomplish two main tasks. Firstly, a range of methodological and conceptual issues associated with the study of migration and utilization behavior are considered. Secondly, a distinction is drawn between two main types of migration and various health status and utilization outcomes. It is clear that considerably more conceptual and methodological refinement is needed before further work is undertaken on the relationship between migration on the one hand, and health status and/or utilization behavior on the other. To this end, hypotheses have been outlined for future empirical testing. While the pertinence of the various issues considered are illustrated with reference to the utilization of health services, they are also seen as having ramifications in such fields as education, welfare, deviance and research methodology.
FOR SEVERAL decades researchers have been describing variations in the etiology and distribution of diseases among people and groups occupying different positions in some social structure. Attempts to ‘explain’ the ways in which one’s position in the social structure tends to affect vulnerability to particular diseases have centered around such factors as age, sex, marital status, religion, ethnic background, socio-economic position, [l-5]. It is thought that any situation, condition or process that alters a person’s position in some established pattern of social interaction, tends to increase their risk to altered health status [6-81. Despite the general acceptance of the view that such positional factors may be variously related to morbidity and mortality, the data available remain fragmentary and speculative. It has been suggested that the studies which generated these findings were exploratory and only incidentally concerned with the role of social factors, that there is a preoccupation with describing whatever social differences can be found in people with and without disease, and that increasingly no demonstrable relationship is being found between such factors and disease prevalence [g-12]. Partly as a consequence of these developments, combined with a dissatisfaction with the somewhat static association between socio-demographic variables and particular diseases, interest has come to center on other social variables which, while still 579
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JOHNB. MCKINLAY
concerned with the relationship between social structural position and health status, embrace a more dynamic set of social circumstances. Among other social phenomena, the migration of human populations provides a unique opportunity to ascertain the relative importance of certain social factors in the development of disease under varying social circumstances. Greater emphasis on aspects of migration would perhaps help to determine whether the social factors, which, at the present time, are purportedly associated with particular diseases, are primary determinants or rather only situationally or indirectly associated. It is not the purpose of this paper to directly review and discuss relationship(s) between migration and health status, but rather to examine selected aspects of migration in an attempt to better understand the influence of this phenomenon on differential utilization behavior. The study of the various effects of migration on health, and health-related behavior, has remained largely unexplored despite the magnitude of the processes involved and the fact that migration probably now constitutes the most important vehicle of social change confronting any society [13, 141. This neglect by health-related researchers-especially medical sociologists and demographers-may have been a consequence of a preoccupation with what are perceived as more pressing issues. As Bogue [ 151 has suggested : ‘Some of the most acute social problemsof the world today are associatedwith migration. If the problemsof human fertility were not so criticalat the present time, it is almostcertain that human migrationand the plightof migrants(especiallyin developingnations)would be listed as a top priority problem for research and action.’
Certainly, current trends would suggest that, rather than decreasing, migration is coming to assume new and unforeseen dimensions, with many attendant social and welfare problems. The need then to understand the effects of migration on utilization behavior for the purposes of formulating and implementing health and welfare policy in an informed way would seem to be paramount. THE
MAGNITUDE
OF THE
PROBLEM
The twentieth century has witnessed the most tumultuous period of international migration of all history. During the thirties and forties, millions of Jews left Nazi Germany; after World War II large numbers of military and civilian political prisoners from defeated nations were conscripted and shipped to labor camps; after the war in the Pacific three million Japanese were returned by decree to Japan; at the time of the partition of India and Pakistan more than seven million Muslims moved from Pakistan to India. Indonesia has expelled much of its Chinese population, while, when mainland China became communist, more than two million Chinese soldiers and civilians migrated to Formosa and Hong Kong. Many people have been displaced by the upheavals in the Middle East, and, as the nations of Eastern Europe changed to a communist form of government, many thousands of political and religious refugees moved into Western Europe, the Americas, Australia and New Zealand, including five million from East Germany to West Berlin and West Germany. Over a million North Koreans fled to South Korea as refugees during or after the Korean War, and this phenomenon was repeated and continues in various ways in Vietnam, Cambodia, Thailand, etc. During the six-month period, March-August, 1971, over eight million Pakistani refugees crossed into India. Recent media reports indicate the presence in the United States of over eight million so-called ‘illegal aliens’-approximately one
Some Issues Associated With Migration, Health Status and the Use of Health Services
581
in New York City alone-who apparently have high needs for health and welfare services [17). In reviewing population migration during the period 1946-1955, Cook [16] estimated that roughly 50 million people migrated from their homelands to some new area. If we add to this the movements between 1930 and 1946, and the expulsive and flight migrations since 1955, the total is now quite possibly in excess of 70 million. In other words, roughly 70 million persons may have migrated in only 40 odd years. To comprehend the magnitude of this movement, it may be noted that the total number of immigrants to the United States during the 145 yr from 1820-1965 was 43 million. In addition to these gross international migrations, of course, one must also consider the movement of people within a particular country. The enormity of this pattern of internal migration is well illustrated in the United States where, according to official reports, approximately 20% of the population change residence year [15, 181. Some have pIaced this figure as high as 27%. There is, of course, an extensive literature concerning the numerous causes, problems and consequences of migration. In the majority of cases, migration involves changing, among other things, one’s national loyalties, foresaking one’s natural language, cultural heritage and customs, kin and friendship networks, and occupation. In many cases, migrants are forced to leave on short notice, selling property at a fraction of its true value, for example. Without prior arrangements in the host community for housing, employment, schooling, and community services, displaced people are often subject to intense economic deprivation and personal humiliation. So drastic are some changes that many adults never make a complete adjustment in their own lifetime, and it is only their children and their grandchildren who are in any way integrated into the receiving society. Studies, mainly from the United States, document the enormous set of health and welfare problems typically associated with such movement from one society to another. Available evidence suggests that such difficulties beset the migrant to any urban industrial society and not merely those who move to the United States. Furthermore, the process appears to vary relatively little whether it involves internal migration from rural to urban areas, or, as is the case of much of the nineteenth century European migration, movement from the rural areas of one country to the urban areas of another. million
SOME QUESTIONS
OF DEFINITION
To date, researchers have employed the term ‘migration’ in a very vague sense to ‘explain’ subsequent phenomena (say an increased incidence in some disease or pattern of behavior) only after the phenomena have been observed and measured. Such explanations are derived from and shaped by the statistics that are already collected, whether or not these have any relevance to the hypotheses being tested. There are several well-known difficulties with this approach. Firstly, there is the difficulty of operationally defining what is meant by ‘migration’ and the consequent problem of measuring, manipulating and testing this variable, once it has been defined. The pertinent literature is replete with attempts to specify what the term ‘migration’ encompasses [15, 19, 201. On a general level, let us first consider migration as intercommunity residential change. All changes in residence, however, cannot be considered migration. Demographers generally regard residential changes from one part of a community to another as local moving and reserve the term migration for residential
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changes from one community to another. Consequently, Shyrock [21] has estimated that, of the residential changes that occurred in 1960 within the United States, approximately 12 million could be classified as migration, and approximately 24 million as local moving. This distinction between migration and local moving is, of course, contingent upon the definition of community. Most researchers suggest that both the distance of the residential move and the amount and quality of change in the social environment of the mover are involved in the distinction between migration and local moving: the hypothesis being that inter-community residential change (migration) involves greater distances and more environmental change than intra-community residential movement (local moving). The assumption underlying this view is that a movement covering a great distance generally involves more environmental change than a move that spans a small distance. In actuality, however, the situation may be quite the reverse: for some social groups, a move that spans a great distance may involve less environmental change than a move that spans a small distance. This may suggest that migration is primarily defined according to inter-community change, rather than distance. A change of community implies, among other things, the severance of old relationships and the establishment of new ones. In addition to the change in living quarters, migration may also involve changes in occupation, school, church, and significant social ties for the migrant and the members of his family. Also relevant to the amount of change involved in a residential move are the characteristics of the sending and receiving communities, characteritics of the migrants, and, of course, the circumstances (whether voluntary or forced) under which the move occurs. The greater the similarity between the sending and the receiving communities, probably the less environmental change there is, regardless of the geographical distance involved. In summary, therefore, it is clear that migration is not a simple concept. It has a number of facets, most of which have some implication for utilization behavior. Migration may be usefully defined as change of residence from one community to another, in contrast to local moving, which can be defined as change of residence within a community. The amount andquality ofchange, rather than merely the distance of the move, is fundamental to this distinction, comprising characteristics of the sending and receiving communities, the characteristics of the migrants involved, and the circumstances under which the move occurs. MIGRATION
AS AN EXPLANATORY
TOOL
OR DESCRIPTIVE
LABEL
Increasingly, the concept or phenomenon of migration is being invoked to explain or make clear the meaning of some relationship or research finding. The usual practice is for migration to be employed ex post facto to crudely explain or interpret some already established or observable relationship or pattern. Seldom is the process of ‘migration’ (however it is defined) measurably built into a research strategy at the design stage. Without the inclusion of migration as an independent or intervening variable in research design, it is possible to invoke any one of a number of different social processes, each of which may equally well ‘explain’ the observable relationship or phenomenon. It seems that migration is currently being employed in a similarly indiscriminate manner to that in which such broad concepts as ‘class’, ‘culture’, ‘religion’, and ‘ethnicity’ have been employed by researchers in the past. Clearly, by invoking migration as an explanation, one suggests a possible set of hypotheses about the specific nature and direction of associations. Often, however, all
Some Issues Associated With Migration, Health Status and the Use of Health Services
583
one knows after migration has been called upon is that a very general social process may be implicated in some observable behaviour or phenomenon. This certainly does not explain why, say, there is a lower rate of medical care utilization among certain migrants or why some migration promotes a higher level of health status for those involved: it merely leads one to ask supplementary ‘why’ questions. An explanation which leads immediately to another question of the same kind is clearly no explanation at all. Very few authors appear to indicate with any precision the purpose they intend the term ‘migration’ to serve. The concept is rather indiscriminately employed, and the reader is sometimes given a brief introduction to the process of migration immediately before its use. The term ‘migration’ is often employed as a descriptive label for some phenomenon or set of phenomena being considered. Sometimes the concept is used as an explanation of some event or process under investigation. Some researchers appear to inadvertently employ both usages simultaneously. If one is using the concept as an explanation, then there should be some clarity as to what precisely one is intending to explain. Alternatively, if the concept is to be employed as a descriptive label, one must be clear regarding what exactly is the class of events being described. To engage in both of these activities is, of course, to engage in two entirely different operations. According to some methodologists, a law of the form ‘E will always occur if A and B are in constant conjunction’ is an indispensable part of an explanation. Unfortunately, migration theorists are not now and never will be in a position to state this sort of law since in the social as in all sciences tendency statements or probabilistic explanations are usually employed-that is, a statement of the form ‘E usually results when A and B are in conjunction’. From such a statement one cannot deduce that if A and B are in conjunction, E will necessarily occur. Given such explanatory difficulties, a number of researchers have concentrated on developing a set of what can be termed ‘intermediate’ or ‘middle range’ concepts which denote phenomena secondarily involved in or associated with migration. Such concepts as role conflict or ambiguity, status inconsistency or incongruity, cultural discontinuity, marginality and alienation have been employed to account for various phenomena thought to be consequent on or associated with migration [9, 22-291. Researchers have also concentrated on what is termed ‘social adaptation’-the ability of people to adapt to a variety of new stimuli, including those symbolic stimuli stemming from a society in which they interact. Rather elaborate instruments have been devised to monitor these processes with quite successful outcomes. With particular reference to the use of the term ‘migration’ as an explanation of the use of health services, a further difficulty arises. A consideration of this particular relationship is complicated by uncertainty as to whether altered utilization behavior is indeed a consequence or a cause of migration. As a cause, we are referring to the behavior of individuals and groups who purposively move so as to either: (a) effect some change in their health status (for example, the move of asthmatics to more favorable climates), and/or (b) avail themselves of certain services not routinely able in their area of origin (for example, temporary moves to New York for interrupted pregnancies, rural-urban moves of New Zealand Maoris for specialist hospital care). With regard to utilization behavior as a consequence of migration, we are referring to the movement of peoples for reasons which, while unrelated to health and illness (for example, expulsive or flight migration), nevertheless result in some alteration in utiliza-
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tion behavior. Such altered behavior may, in this situation, be with or without some alteration in health status. The increasing fragmentation of health care systems resulting in regional and national inconsistencies, combined with improved communication and faster travel, may increasingly encourage wide-spread population movement for the explicit purpose of obtaining short-term medical care. Judging from reports of patient intake for abortion facilities in London and New York, it appears that, for this service at least, there is a large-scale, short-term movement of the relevant population with the explicit intention of utilizing a service which was unavailable or inaccessible in the area of origin. There is a suggestion that a similar move may be occuring in other nations among persons seeking health care for venereal diseases. Relevant also in this regard may be the outcome of the measures currently being considered to enact some form of national health insurance in the United States. If such attempts fail, it is possible to conceive of a situation in which people faced with certain health needs and soaring medical costs will even move across national boundaries to Britain, Canada or Sweden, for example, where some form of nationalized health service exists, in order to obtain more reasonably priced medical care. Indeed, should the need arise, it will probably soon be cheaper for this author and his family to fly to London for a prolonged course of dental treatment under the British National Health Service than to receive and pay for such care in the United States. Generally speaking, however, it appears that few people engage in long-term moves for the explicit purpose of effecting some improvement in their health status, or to avail themselves of new services for a prolonged period. Moreover, it is doubtful whether very much of modern-day illness (cancer, heart disease, emphysema, etc.) would be significantly affected by permanent residential moves to supposedly more favorable climates, although the fashionable, current concern over the quality of the environment may precipitate population movement in the future for the purpose of altering health status or perhaps minimizing one’s susceptibility to certain conditions. WHAT
TIME
PERJOD
IS INVOLVED?
Another common difficulty in work on migration is the tendency for researchers to isolate a pattern of migration for one particular group of people and to assume that it is both homogeneous in composition, and that it involves quite uniform motives or underlying environmental precipitants for all those associated with it. Such assumption fail to adequately consider both the inner heterogeneity of migratory movements, and the variability in underlying causes. Even within the same general migration, quite different social groups or categories may become involved over time, who act in response to different motives or environmental precipitants. The question of the changing composition of a single migration over time calls to mind the problem of the ‘ever rolling stream’ posed by Heraclitus when he reminded his audience that one cannot step twice into the same river, for the water into which one had first stepped would by now have flowed on and other water would have taken its place. Certainly, it is essential to consider: (a) The point in time or the stage in the migration process involved; (b) The socio-demographic composition of the groups involved; (c) The possibility that the precipitating factors causing the movement of one group may not be the same for all other or subsequent groups; and (d) That the consequences of migration (in terms of either health status or utilization behavior) may be
Some IssuesAssociatedWith Migration,Health Status and the Use of Health Services 585 different for certain groups over time. Even though we are looking at the same general migration, we may, at different points in time, be looking at different groups who are responding to different motives with different consequences for health status and utilization [30]. A movement which originates as a result of some threatening life condition for a particular group can develop into an established pattern of movement-some form of collective behavior-involving different people, acting on the basis of quite different motives, with quite different results. Lindberg [31] has described in detail overseas movements from Sweden during the nineteenth century, and his work affords an excellent illustration of the phenomenon being discussed. The three periods or stages identified in this migration process each appeared to involve a characteristic type of migrant. During theJirst stage, beginning around 1840, emigrants came principally from two university towns and they were ‘men with a good cultural and social background, mostly young and of a romantic disposition’. The social significance of this pioneer movement apparently lay not in its size, but in the example it set. It was this emigration which helped to ‘break the ice’ and pave the way for the later movement which included quite different social groups. The pioneers wrote letters home and their adventures in the new world were recounted with color in Swedish newspapers. The second stage consisted of group migration-for example, the emigration of Pietist communities under the leadership of their pastor. Again, the significance of this group migration lay not in its size but in the impulse it gave to subsequent movement. The third stage consisted of a social movement of people whose principal reason for migration appeared to be simply the prior migration of other Swedes. Lindberg [31] comments: ‘When they finally arrived at a decision, they merely followed a tradition which made emigration a natural thing in a certain situation. In fact, after the imagination and fantasy had, so to speak, become charged with America, a positive decision not to emigrate may have been necessary if difficulties arose’. A similar pattern of different stages may also be detectable for Irish and Italian migrations to the United States, the movement of blacks from rural to metropolitan areas in the United States, Britons to Australasia, and perhaps Polynesians to New Zealand. The significance of all this for both health status and utilization behavior is quite clear: at different points in time, different social categories, acting on the basis of different precipitating factors and with different needs, may be implicated. Furthermore, there are obvious implications for social planning and policy for migrants. It may, for example, be erroneous to plan future health facilities on the basis of projections of needs estimated from ‘stage one’ migrants. Moreover, it is well known that there are marked differences in the causes of migration for, say, lower and higher socio-economic groups, and these may affect actual and perceived needs and subsequent utilization behavior. Lower status groups may, for example, migrate to avoid inadequacies or uncertainties in the community of origin, while higher status groups may move so as to grasp opportunities otherwise unavailable to them at home. Consequently, people of lower socio-economic status may be unclear about the work in which they will engage, the place in which they will live, or the people with whom they will associate-all of which may intensify the need for external socio-emotional resources and perhaps to utilize formal health and welfare services. Such uncertainties, and the resulting needs, may not be present to the same degree among higher status migrants.
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JOHNB. MCKINLAY
A number of studies have explored some of the reasons for the failure of lower status groups to assimilate or adjust to new cultures after migration. It has, for example, been shown that lower status people are more likely than higher status migrants to move to a particular area because they have relatives and friends there who can support them after arrival [19, 32-351. Some researchers have suggested that such protection of immigrant groups in the new society may impede their assimilation by perpetuating old customs, language, beliefs, and life styles. Such mechanisms will be discussed further, while considering their effects on the visibility of immigrant groups and the detectability of disorders. DIFFERENTIAL
VISIBILITY
AND
DETECTABILITY
Apart from the difficulties already outlined, some apparently conflicting findings over whether migration really does alter the health status of migrants, and the ways in which they utilize services, may be partly due to their visibility in relation to the host population and the probability that they will be ‘detected’ and differentially labelled as in some kind of need. There is no reason why this phenomenon-repeatedly shown to exist in the differential apprehension of blacks for crimes or mental illness in the United States-should not also be operating with respect to utilization behavior by migrants [36-391. Such a phenomenon may also partially explain the apparently conllicting findings with regard to health status and utilization behavior between quite separate migrations to the same country, as well as variations over time for what is regarded as the same general pattern of migration. In the$rst case, certain groups may be more easily distinguished from those in the host society than those involved in some other migration (contrast, for example, Irish and Puerto Rican migrants to Northeast America). In the second case, at an early point of the migration, certain groups of individuals may be initially distinguishable from those in the host culture and differentially treated by health and welfare professionals and agencies. Over time, however, the relative proportion of certain groups may change, as may the conception of need among them. This in turn may affect their visibility with a consequent change in utilization behavior. If the rates of morbidity were equal among migrants and nonmigrants, the fact that a substantial proportion of migrants are without families or anyone to shelter them would perhaps increase the likelihood of their detection and subsequent treatment. The nonmigrant with the same condition may be protected by the family and may in preference consult among lay members of already existing social networks. Such behavior has been shown to exist with regard to mental illness where families may attempt to ‘normalize’ unusual behavior, with obvious effects on subsequent utilization rates for health services [40, 411. It was mentioned earlier that migrants of low socio-economic status tend to move into already existing primary groups of similarly circumstanced people in the host society. Such primary groups may also insulate a newcomer from the wider society and similarly conceal needs by facilitating extensive lay consultation and self-medication. Although previously neglected, this matter of differential visibility and detectability has now become particularly important in light of recent media accounts of the SOcalled ‘silent invasion’ of an estimated eight million ‘illegal aliens’ to the United States [17]. Reports from the U.S. Immigration and Naturalization Service reveal that, despite pressing health and welfare needs, most of these aliens underutilize such
Some Issues Associated With Migration, Health Status and the Use of Health
Services 587
services as welfare, medical and medicaid for fear that their illegal status will be discovered and that deportation will result. (In order to qualify for most basic services in the U.S., one must usually possess a social security number for the purposes of establishing identity.) From the admittedly fragmentary reports available, it appears that these aliens underutilize services which pose the greatest risk to exposure-for which, unfortunately, there are often the greatest needs (for example, hospitals and various welfare agencies, such as housing and unemployment)-and utilize those services where the threat to exposure appears minimal (for example, schools and unregulated private employment agencies). TYPES
OF MIGRATION
AND
BEHAVIORAL
OUTCOMES
The evidence supporting the view that migration is either deleterious or beneficial to health, and results in an increase or reduction in utilization behavior, is fragmentary and equivocal. For a long time it has been maintained that since migration is generally favorably selective in terms of age, sex, socio-economic status and perhaps I.Q. (international voluntary migrants, for example, tend to be males, aged 25-40, and white collar or skilled manual workers), and because the prevalence of morbidity is known to be relatively low in groups with such favorable characteristics, migrants have appeared to be as healthy as, if not more healthy than, comparable groups in receiving societies. In apparent contradiction, others maintain that migration usually involves groups which are most affected by poverty, homelessness, unemployment, etc. in their countries of origin and, hence, move to new areas to ameliorate their life situation. Such groups are generally of poorer health status and may, therefore, be comparatively worse off in their new areas of residence. It is not the intention here to support one view or the other, except to say that while poverty, misery, debt, expanding population, and agricultural vicissitudes in many ways affected the poor in England, Ireland, Germany, Poland, Italy, and Sweden, and must be held responsible to some extent as ‘push factors toward out migration, they were not sujicient conditions for the movement of the very poor. Most historians now subscribe to the view that those selective factors which do operate give precedence to the ablebodied, the effective, and those who can afford the costs of passage. Balch [42], discussing European migration, reports that those districts in direct and most settled poverty were not the major sources of migration. Foerster [43] reports a similar situation in the distribution of emigration from southern Italy. Walker [44] describes the German emigration as one of the predominantly lower middle classes and rural craftsmen. Data from Britain suggest that, despite strong encouragement, the poor were highly resistent to emigration, while skilled labor, displaced by machinery, eagerly went to the United States [45, 461. This view is supported by data from the United States, which indicates the educational superiority of migrants, compared with those remaining in the home community [47, 481. Thus, it seems that social and economic deprivation, while frequently a precipitating factor, cannot be regarded as a sufficient condition for migration. The historical factors regarding migration selectively are, however, only part of the picture. To a large extent, the confusion over the effect of migration on health status stems from the failure to specify which particular type of migration one is considering. For example, the view that migrants are healthy is probably true if migration is a matter of free choice. When, however, migration is primarily involuntary, where people
588
JOHNB. MCKINLAY
have to move home out of necessity for fear of their lives or because of loss of opportunity of earning a living, different kinds of people may become involved, with quite different consequences for health and subsequent utilization behavior. The differences between voluntary and expulsive or flight migration, for example, may be illustrated by comparing the characteristics of people involved in the ‘brain drain’ movement from the Antipodes to Great Britain, and from Britain to the United States, and the characteristics of those involved in movements from Pakistan to India, North to South Vietnam, or the present Polynesian migration to New Zealand. In the former cases, migration is biased in favor of social groups at low risk to morbidity, while, in the latter three cases, migration probably involves groups of more heterogeneous composition, whose members are at generally higher risk to morbidity and even mortality, with probably quite different disease distributions. The demands on health services from such different groups will also be very different in the host culture. To my knowledge, a distinction has never been made in the literature between the types or nature of migration and subsequent utilization behavior. In the past, researchers have examined the behavior of dzferent populations involved in d@rent types of migration at dierent points in time with, understandably, different (but not necessarily conflicting) results. Since it has been established that specific types of mental illness may be related to specific types of population movement [49-511, it is reasonable to expect that a similar situation may exist with respect to utilization behavior. Some suggestive leads, with regard to the relationship between migration and utilization behavior, are offered in a typology developed for other purposes by Peterson [52] which distinguish between different causes, classes and types of migration. By extending this work to the area of health status and utilization behavior, it may be possible to tease out the pertinent relationships and clarify apparently conflicting findings. MIGRATION,
HEALTH
STATUS
AND
UTILIZATION
BEHAVIOR
Most researchers either directly or implicitly subscribe to the view that utilization behavior is a fairly accurate reflection of the nature and distribution of pathology in a community. This view appears to stem from the somewhat naive, over-rationalized conception of man which suggests that people, in the area of health at least, always act on the basis of self-recognized, role-impairing symptoms. Accordingly, any general increase in service utilization is thought to result from some increase in morbidity in the community, and any decrease is a consequence of some improvement in health status. Such a simplistic model, of course, obscures the complexities of the real situation. With regard to migration, for example, a move to a new location may result in some increase in preventive health behavior (due to the predominant orientation of the medical institution in the new host country) with no obvious change in health status. Similarly, new residents to an area with enduring illness conditions may utilize newly available curative facilities for which there was no comparable service in the country or area of origin. With regard to the relationship. between migration, health status, and utilization behavior, therefore, it may be fruitful to distinguish four distinct situations as follows: (1) The case where there is no alteration in health status and no alteration in utilization behavior;
Some Issues Associated With Migration, Health Status and the Use of Health Services
589
(2) The case where there is no alteration in health status but some alteration in utilization behavior ; (3) The case where there is some alteration in health status but no alteration in utilization behavior ; (4) The case where there is some alteration in health status and some alteration in utilization behavior.* Shuval [53] has recently examined the case where there is no alteration in health status but some alteration in utilization behavior, with a study of a prepaid medical insurance system which serves the majority of the population of Israel, comprising voluntary immigrants. Although the rate of medical care utilization in Israel is one of the highest in the world, existing patterns of morbidity in that country do not adequately account for this phenomenon. The central focus of this rare study of overutilization and migration was on the latent function of the medical system for migrant Israelis, This concern with latent, rather than manifest, functions resulted in a concentration on non-medical needs, of which Shuval isolated five, namely: (1) the need for catharsis or some contact which permits free communication; (2) the need to cope with failure-using illness as a legitimizing mechanism; (3) the need for integration into the social system through contact with a well-established social institution; (4) the need to attain high status through contact with high status physicians; (5) the need for resolution of the magico-science conflict, or for allaying certain health superstitions and affirming modern medical science. Given that one should distinguish between at least the two broad types of migration already referred to (voluntary and involuntary) and the four possible combinations of health status and utilization behavior outlined, a threefold typology can be constructed (see Fig. 1).
Voluntary
I,
H. S. and U. B No change
migration
Involuntary
//l/i// 2. H S No change’ j///j/ ’ ’ ///
/U./B. //
I. H S. and U. B.
(ha”
SOME ISSUES ASSOCIATED WITH MIGRATION, HEALTH STATUS AND THE USE OF HEALTH SERVICES* JOHN B. MCKINLAY Department
of Sociology, Boston University and Massachusetts (Primary Care Unit), Boston, Massachusetts
General Hospital
(Received in revised form 4 February 1975)
Abstract-In comparison with other areas of Medical Sociology, the study of the various effects of migration on health and health-related behavior has remained largely unexplored, despite the magnitude of the processes involved and the fact that migration now probably constitutes the most important vehicle of social change confronting any society. This paper attempts to accomplish two main tasks. Firstly, a range of methodological and conceptual issues associated with the study of migration and utilization behavior are considered. Secondly, a distinction is drawn between two main types of migration and various health status and utilization outcomes. It is clear that considerably more conceptual and methodological refinement is needed before further work is undertaken on the relationship between migration on the one hand, and health status and/or utilization behavior on the other. To this end, hypotheses have been outlined for future empirical testing. While the pertinence of the various issues considered are illustrated with reference to the utilization of health services, they are also seen as having ramifications in such fields as education, welfare, deviance and research methodology.
FOR SEVERAL decades researchers have been describing variations in the etiology and distribution of diseases among people and groups occupying different positions in some social structure. Attempts to ‘explain’ the ways in which one’s position in the social structure tends to affect vulnerability to particular diseases have centered around such factors as age, sex, marital status, religion, ethnic background, socio-economic position, [l-5]. It is thought that any situation, condition or process that alters a person’s position in some established pattern of social interaction, tends to increase their risk to altered health status [6-81. Despite the general acceptance of the view that such positional factors may be variously related to morbidity and mortality, the data available remain fragmentary and speculative. It has been suggested that the studies which generated these findings were exploratory and only incidentally concerned with the role of social factors, that there is a preoccupation with describing whatever social differences can be found in people with and without disease, and that increasingly no demonstrable relationship is being found between such factors and disease prevalence [g-12]. Partly as a consequence of these developments, combined with a dissatisfaction with the somewhat static association between socio-demographic variables and particular diseases, interest has come to center on other social variables which, while still 579
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JOHNB. MCKINLAY
concerned with the relationship between social structural position and health status, embrace a more dynamic set of social circumstances. Among other social phenomena, the migration of human populations provides a unique opportunity to ascertain the relative importance of certain social factors in the development of disease under varying social circumstances. Greater emphasis on aspects of migration would perhaps help to determine whether the social factors, which, at the present time, are purportedly associated with particular diseases, are primary determinants or rather only situationally or indirectly associated. It is not the purpose of this paper to directly review and discuss relationship(s) between migration and health status, but rather to examine selected aspects of migration in an attempt to better understand the influence of this phenomenon on differential utilization behavior. The study of the various effects of migration on health, and health-related behavior, has remained largely unexplored despite the magnitude of the processes involved and the fact that migration probably now constitutes the most important vehicle of social change confronting any society [13, 141. This neglect by health-related researchers-especially medical sociologists and demographers-may have been a consequence of a preoccupation with what are perceived as more pressing issues. As Bogue [ 151 has suggested : ‘Some of the most acute social problemsof the world today are associatedwith migration. If the problemsof human fertility were not so criticalat the present time, it is almostcertain that human migrationand the plightof migrants(especiallyin developingnations)would be listed as a top priority problem for research and action.’
Certainly, current trends would suggest that, rather than decreasing, migration is coming to assume new and unforeseen dimensions, with many attendant social and welfare problems. The need then to understand the effects of migration on utilization behavior for the purposes of formulating and implementing health and welfare policy in an informed way would seem to be paramount. THE
MAGNITUDE
OF THE
PROBLEM
The twentieth century has witnessed the most tumultuous period of international migration of all history. During the thirties and forties, millions of Jews left Nazi Germany; after World War II large numbers of military and civilian political prisoners from defeated nations were conscripted and shipped to labor camps; after the war in the Pacific three million Japanese were returned by decree to Japan; at the time of the partition of India and Pakistan more than seven million Muslims moved from Pakistan to India. Indonesia has expelled much of its Chinese population, while, when mainland China became communist, more than two million Chinese soldiers and civilians migrated to Formosa and Hong Kong. Many people have been displaced by the upheavals in the Middle East, and, as the nations of Eastern Europe changed to a communist form of government, many thousands of political and religious refugees moved into Western Europe, the Americas, Australia and New Zealand, including five million from East Germany to West Berlin and West Germany. Over a million North Koreans fled to South Korea as refugees during or after the Korean War, and this phenomenon was repeated and continues in various ways in Vietnam, Cambodia, Thailand, etc. During the six-month period, March-August, 1971, over eight million Pakistani refugees crossed into India. Recent media reports indicate the presence in the United States of over eight million so-called ‘illegal aliens’-approximately one
Some Issues Associated With Migration, Health Status and the Use of Health Services
581
in New York City alone-who apparently have high needs for health and welfare services [17). In reviewing population migration during the period 1946-1955, Cook [16] estimated that roughly 50 million people migrated from their homelands to some new area. If we add to this the movements between 1930 and 1946, and the expulsive and flight migrations since 1955, the total is now quite possibly in excess of 70 million. In other words, roughly 70 million persons may have migrated in only 40 odd years. To comprehend the magnitude of this movement, it may be noted that the total number of immigrants to the United States during the 145 yr from 1820-1965 was 43 million. In addition to these gross international migrations, of course, one must also consider the movement of people within a particular country. The enormity of this pattern of internal migration is well illustrated in the United States where, according to official reports, approximately 20% of the population change residence year [15, 181. Some have pIaced this figure as high as 27%. There is, of course, an extensive literature concerning the numerous causes, problems and consequences of migration. In the majority of cases, migration involves changing, among other things, one’s national loyalties, foresaking one’s natural language, cultural heritage and customs, kin and friendship networks, and occupation. In many cases, migrants are forced to leave on short notice, selling property at a fraction of its true value, for example. Without prior arrangements in the host community for housing, employment, schooling, and community services, displaced people are often subject to intense economic deprivation and personal humiliation. So drastic are some changes that many adults never make a complete adjustment in their own lifetime, and it is only their children and their grandchildren who are in any way integrated into the receiving society. Studies, mainly from the United States, document the enormous set of health and welfare problems typically associated with such movement from one society to another. Available evidence suggests that such difficulties beset the migrant to any urban industrial society and not merely those who move to the United States. Furthermore, the process appears to vary relatively little whether it involves internal migration from rural to urban areas, or, as is the case of much of the nineteenth century European migration, movement from the rural areas of one country to the urban areas of another. million
SOME QUESTIONS
OF DEFINITION
To date, researchers have employed the term ‘migration’ in a very vague sense to ‘explain’ subsequent phenomena (say an increased incidence in some disease or pattern of behavior) only after the phenomena have been observed and measured. Such explanations are derived from and shaped by the statistics that are already collected, whether or not these have any relevance to the hypotheses being tested. There are several well-known difficulties with this approach. Firstly, there is the difficulty of operationally defining what is meant by ‘migration’ and the consequent problem of measuring, manipulating and testing this variable, once it has been defined. The pertinent literature is replete with attempts to specify what the term ‘migration’ encompasses [15, 19, 201. On a general level, let us first consider migration as intercommunity residential change. All changes in residence, however, cannot be considered migration. Demographers generally regard residential changes from one part of a community to another as local moving and reserve the term migration for residential
582
JOHNB. MCKINLAY
changes from one community to another. Consequently, Shyrock [21] has estimated that, of the residential changes that occurred in 1960 within the United States, approximately 12 million could be classified as migration, and approximately 24 million as local moving. This distinction between migration and local moving is, of course, contingent upon the definition of community. Most researchers suggest that both the distance of the residential move and the amount and quality of change in the social environment of the mover are involved in the distinction between migration and local moving: the hypothesis being that inter-community residential change (migration) involves greater distances and more environmental change than intra-community residential movement (local moving). The assumption underlying this view is that a movement covering a great distance generally involves more environmental change than a move that spans a small distance. In actuality, however, the situation may be quite the reverse: for some social groups, a move that spans a great distance may involve less environmental change than a move that spans a small distance. This may suggest that migration is primarily defined according to inter-community change, rather than distance. A change of community implies, among other things, the severance of old relationships and the establishment of new ones. In addition to the change in living quarters, migration may also involve changes in occupation, school, church, and significant social ties for the migrant and the members of his family. Also relevant to the amount of change involved in a residential move are the characteristics of the sending and receiving communities, characteritics of the migrants, and, of course, the circumstances (whether voluntary or forced) under which the move occurs. The greater the similarity between the sending and the receiving communities, probably the less environmental change there is, regardless of the geographical distance involved. In summary, therefore, it is clear that migration is not a simple concept. It has a number of facets, most of which have some implication for utilization behavior. Migration may be usefully defined as change of residence from one community to another, in contrast to local moving, which can be defined as change of residence within a community. The amount andquality ofchange, rather than merely the distance of the move, is fundamental to this distinction, comprising characteristics of the sending and receiving communities, the characteristics of the migrants involved, and the circumstances under which the move occurs. MIGRATION
AS AN EXPLANATORY
TOOL
OR DESCRIPTIVE
LABEL
Increasingly, the concept or phenomenon of migration is being invoked to explain or make clear the meaning of some relationship or research finding. The usual practice is for migration to be employed ex post facto to crudely explain or interpret some already established or observable relationship or pattern. Seldom is the process of ‘migration’ (however it is defined) measurably built into a research strategy at the design stage. Without the inclusion of migration as an independent or intervening variable in research design, it is possible to invoke any one of a number of different social processes, each of which may equally well ‘explain’ the observable relationship or phenomenon. It seems that migration is currently being employed in a similarly indiscriminate manner to that in which such broad concepts as ‘class’, ‘culture’, ‘religion’, and ‘ethnicity’ have been employed by researchers in the past. Clearly, by invoking migration as an explanation, one suggests a possible set of hypotheses about the specific nature and direction of associations. Often, however, all
Some Issues Associated With Migration, Health Status and the Use of Health Services
583
one knows after migration has been called upon is that a very general social process may be implicated in some observable behaviour or phenomenon. This certainly does not explain why, say, there is a lower rate of medical care utilization among certain migrants or why some migration promotes a higher level of health status for those involved: it merely leads one to ask supplementary ‘why’ questions. An explanation which leads immediately to another question of the same kind is clearly no explanation at all. Very few authors appear to indicate with any precision the purpose they intend the term ‘migration’ to serve. The concept is rather indiscriminately employed, and the reader is sometimes given a brief introduction to the process of migration immediately before its use. The term ‘migration’ is often employed as a descriptive label for some phenomenon or set of phenomena being considered. Sometimes the concept is used as an explanation of some event or process under investigation. Some researchers appear to inadvertently employ both usages simultaneously. If one is using the concept as an explanation, then there should be some clarity as to what precisely one is intending to explain. Alternatively, if the concept is to be employed as a descriptive label, one must be clear regarding what exactly is the class of events being described. To engage in both of these activities is, of course, to engage in two entirely different operations. According to some methodologists, a law of the form ‘E will always occur if A and B are in constant conjunction’ is an indispensable part of an explanation. Unfortunately, migration theorists are not now and never will be in a position to state this sort of law since in the social as in all sciences tendency statements or probabilistic explanations are usually employed-that is, a statement of the form ‘E usually results when A and B are in conjunction’. From such a statement one cannot deduce that if A and B are in conjunction, E will necessarily occur. Given such explanatory difficulties, a number of researchers have concentrated on developing a set of what can be termed ‘intermediate’ or ‘middle range’ concepts which denote phenomena secondarily involved in or associated with migration. Such concepts as role conflict or ambiguity, status inconsistency or incongruity, cultural discontinuity, marginality and alienation have been employed to account for various phenomena thought to be consequent on or associated with migration [9, 22-291. Researchers have also concentrated on what is termed ‘social adaptation’-the ability of people to adapt to a variety of new stimuli, including those symbolic stimuli stemming from a society in which they interact. Rather elaborate instruments have been devised to monitor these processes with quite successful outcomes. With particular reference to the use of the term ‘migration’ as an explanation of the use of health services, a further difficulty arises. A consideration of this particular relationship is complicated by uncertainty as to whether altered utilization behavior is indeed a consequence or a cause of migration. As a cause, we are referring to the behavior of individuals and groups who purposively move so as to either: (a) effect some change in their health status (for example, the move of asthmatics to more favorable climates), and/or (b) avail themselves of certain services not routinely able in their area of origin (for example, temporary moves to New York for interrupted pregnancies, rural-urban moves of New Zealand Maoris for specialist hospital care). With regard to utilization behavior as a consequence of migration, we are referring to the movement of peoples for reasons which, while unrelated to health and illness (for example, expulsive or flight migration), nevertheless result in some alteration in utiliza-
584
JOHN B. MCKINLAY
tion behavior. Such altered behavior may, in this situation, be with or without some alteration in health status. The increasing fragmentation of health care systems resulting in regional and national inconsistencies, combined with improved communication and faster travel, may increasingly encourage wide-spread population movement for the explicit purpose of obtaining short-term medical care. Judging from reports of patient intake for abortion facilities in London and New York, it appears that, for this service at least, there is a large-scale, short-term movement of the relevant population with the explicit intention of utilizing a service which was unavailable or inaccessible in the area of origin. There is a suggestion that a similar move may be occuring in other nations among persons seeking health care for venereal diseases. Relevant also in this regard may be the outcome of the measures currently being considered to enact some form of national health insurance in the United States. If such attempts fail, it is possible to conceive of a situation in which people faced with certain health needs and soaring medical costs will even move across national boundaries to Britain, Canada or Sweden, for example, where some form of nationalized health service exists, in order to obtain more reasonably priced medical care. Indeed, should the need arise, it will probably soon be cheaper for this author and his family to fly to London for a prolonged course of dental treatment under the British National Health Service than to receive and pay for such care in the United States. Generally speaking, however, it appears that few people engage in long-term moves for the explicit purpose of effecting some improvement in their health status, or to avail themselves of new services for a prolonged period. Moreover, it is doubtful whether very much of modern-day illness (cancer, heart disease, emphysema, etc.) would be significantly affected by permanent residential moves to supposedly more favorable climates, although the fashionable, current concern over the quality of the environment may precipitate population movement in the future for the purpose of altering health status or perhaps minimizing one’s susceptibility to certain conditions. WHAT
TIME
PERJOD
IS INVOLVED?
Another common difficulty in work on migration is the tendency for researchers to isolate a pattern of migration for one particular group of people and to assume that it is both homogeneous in composition, and that it involves quite uniform motives or underlying environmental precipitants for all those associated with it. Such assumption fail to adequately consider both the inner heterogeneity of migratory movements, and the variability in underlying causes. Even within the same general migration, quite different social groups or categories may become involved over time, who act in response to different motives or environmental precipitants. The question of the changing composition of a single migration over time calls to mind the problem of the ‘ever rolling stream’ posed by Heraclitus when he reminded his audience that one cannot step twice into the same river, for the water into which one had first stepped would by now have flowed on and other water would have taken its place. Certainly, it is essential to consider: (a) The point in time or the stage in the migration process involved; (b) The socio-demographic composition of the groups involved; (c) The possibility that the precipitating factors causing the movement of one group may not be the same for all other or subsequent groups; and (d) That the consequences of migration (in terms of either health status or utilization behavior) may be
Some IssuesAssociatedWith Migration,Health Status and the Use of Health Services 585 different for certain groups over time. Even though we are looking at the same general migration, we may, at different points in time, be looking at different groups who are responding to different motives with different consequences for health status and utilization [30]. A movement which originates as a result of some threatening life condition for a particular group can develop into an established pattern of movement-some form of collective behavior-involving different people, acting on the basis of quite different motives, with quite different results. Lindberg [31] has described in detail overseas movements from Sweden during the nineteenth century, and his work affords an excellent illustration of the phenomenon being discussed. The three periods or stages identified in this migration process each appeared to involve a characteristic type of migrant. During theJirst stage, beginning around 1840, emigrants came principally from two university towns and they were ‘men with a good cultural and social background, mostly young and of a romantic disposition’. The social significance of this pioneer movement apparently lay not in its size, but in the example it set. It was this emigration which helped to ‘break the ice’ and pave the way for the later movement which included quite different social groups. The pioneers wrote letters home and their adventures in the new world were recounted with color in Swedish newspapers. The second stage consisted of group migration-for example, the emigration of Pietist communities under the leadership of their pastor. Again, the significance of this group migration lay not in its size but in the impulse it gave to subsequent movement. The third stage consisted of a social movement of people whose principal reason for migration appeared to be simply the prior migration of other Swedes. Lindberg [31] comments: ‘When they finally arrived at a decision, they merely followed a tradition which made emigration a natural thing in a certain situation. In fact, after the imagination and fantasy had, so to speak, become charged with America, a positive decision not to emigrate may have been necessary if difficulties arose’. A similar pattern of different stages may also be detectable for Irish and Italian migrations to the United States, the movement of blacks from rural to metropolitan areas in the United States, Britons to Australasia, and perhaps Polynesians to New Zealand. The significance of all this for both health status and utilization behavior is quite clear: at different points in time, different social categories, acting on the basis of different precipitating factors and with different needs, may be implicated. Furthermore, there are obvious implications for social planning and policy for migrants. It may, for example, be erroneous to plan future health facilities on the basis of projections of needs estimated from ‘stage one’ migrants. Moreover, it is well known that there are marked differences in the causes of migration for, say, lower and higher socio-economic groups, and these may affect actual and perceived needs and subsequent utilization behavior. Lower status groups may, for example, migrate to avoid inadequacies or uncertainties in the community of origin, while higher status groups may move so as to grasp opportunities otherwise unavailable to them at home. Consequently, people of lower socio-economic status may be unclear about the work in which they will engage, the place in which they will live, or the people with whom they will associate-all of which may intensify the need for external socio-emotional resources and perhaps to utilize formal health and welfare services. Such uncertainties, and the resulting needs, may not be present to the same degree among higher status migrants.
586
JOHNB. MCKINLAY
A number of studies have explored some of the reasons for the failure of lower status groups to assimilate or adjust to new cultures after migration. It has, for example, been shown that lower status people are more likely than higher status migrants to move to a particular area because they have relatives and friends there who can support them after arrival [19, 32-351. Some researchers have suggested that such protection of immigrant groups in the new society may impede their assimilation by perpetuating old customs, language, beliefs, and life styles. Such mechanisms will be discussed further, while considering their effects on the visibility of immigrant groups and the detectability of disorders. DIFFERENTIAL
VISIBILITY
AND
DETECTABILITY
Apart from the difficulties already outlined, some apparently conflicting findings over whether migration really does alter the health status of migrants, and the ways in which they utilize services, may be partly due to their visibility in relation to the host population and the probability that they will be ‘detected’ and differentially labelled as in some kind of need. There is no reason why this phenomenon-repeatedly shown to exist in the differential apprehension of blacks for crimes or mental illness in the United States-should not also be operating with respect to utilization behavior by migrants [36-391. Such a phenomenon may also partially explain the apparently conllicting findings with regard to health status and utilization behavior between quite separate migrations to the same country, as well as variations over time for what is regarded as the same general pattern of migration. In the$rst case, certain groups may be more easily distinguished from those in the host society than those involved in some other migration (contrast, for example, Irish and Puerto Rican migrants to Northeast America). In the second case, at an early point of the migration, certain groups of individuals may be initially distinguishable from those in the host culture and differentially treated by health and welfare professionals and agencies. Over time, however, the relative proportion of certain groups may change, as may the conception of need among them. This in turn may affect their visibility with a consequent change in utilization behavior. If the rates of morbidity were equal among migrants and nonmigrants, the fact that a substantial proportion of migrants are without families or anyone to shelter them would perhaps increase the likelihood of their detection and subsequent treatment. The nonmigrant with the same condition may be protected by the family and may in preference consult among lay members of already existing social networks. Such behavior has been shown to exist with regard to mental illness where families may attempt to ‘normalize’ unusual behavior, with obvious effects on subsequent utilization rates for health services [40, 411. It was mentioned earlier that migrants of low socio-economic status tend to move into already existing primary groups of similarly circumstanced people in the host society. Such primary groups may also insulate a newcomer from the wider society and similarly conceal needs by facilitating extensive lay consultation and self-medication. Although previously neglected, this matter of differential visibility and detectability has now become particularly important in light of recent media accounts of the SOcalled ‘silent invasion’ of an estimated eight million ‘illegal aliens’ to the United States [17]. Reports from the U.S. Immigration and Naturalization Service reveal that, despite pressing health and welfare needs, most of these aliens underutilize such
Some Issues Associated With Migration, Health Status and the Use of Health
Services 587
services as welfare, medical and medicaid for fear that their illegal status will be discovered and that deportation will result. (In order to qualify for most basic services in the U.S., one must usually possess a social security number for the purposes of establishing identity.) From the admittedly fragmentary reports available, it appears that these aliens underutilize services which pose the greatest risk to exposure-for which, unfortunately, there are often the greatest needs (for example, hospitals and various welfare agencies, such as housing and unemployment)-and utilize those services where the threat to exposure appears minimal (for example, schools and unregulated private employment agencies). TYPES
OF MIGRATION
AND
BEHAVIORAL
OUTCOMES
The evidence supporting the view that migration is either deleterious or beneficial to health, and results in an increase or reduction in utilization behavior, is fragmentary and equivocal. For a long time it has been maintained that since migration is generally favorably selective in terms of age, sex, socio-economic status and perhaps I.Q. (international voluntary migrants, for example, tend to be males, aged 25-40, and white collar or skilled manual workers), and because the prevalence of morbidity is known to be relatively low in groups with such favorable characteristics, migrants have appeared to be as healthy as, if not more healthy than, comparable groups in receiving societies. In apparent contradiction, others maintain that migration usually involves groups which are most affected by poverty, homelessness, unemployment, etc. in their countries of origin and, hence, move to new areas to ameliorate their life situation. Such groups are generally of poorer health status and may, therefore, be comparatively worse off in their new areas of residence. It is not the intention here to support one view or the other, except to say that while poverty, misery, debt, expanding population, and agricultural vicissitudes in many ways affected the poor in England, Ireland, Germany, Poland, Italy, and Sweden, and must be held responsible to some extent as ‘push factors toward out migration, they were not sujicient conditions for the movement of the very poor. Most historians now subscribe to the view that those selective factors which do operate give precedence to the ablebodied, the effective, and those who can afford the costs of passage. Balch [42], discussing European migration, reports that those districts in direct and most settled poverty were not the major sources of migration. Foerster [43] reports a similar situation in the distribution of emigration from southern Italy. Walker [44] describes the German emigration as one of the predominantly lower middle classes and rural craftsmen. Data from Britain suggest that, despite strong encouragement, the poor were highly resistent to emigration, while skilled labor, displaced by machinery, eagerly went to the United States [45, 461. This view is supported by data from the United States, which indicates the educational superiority of migrants, compared with those remaining in the home community [47, 481. Thus, it seems that social and economic deprivation, while frequently a precipitating factor, cannot be regarded as a sufficient condition for migration. The historical factors regarding migration selectively are, however, only part of the picture. To a large extent, the confusion over the effect of migration on health status stems from the failure to specify which particular type of migration one is considering. For example, the view that migrants are healthy is probably true if migration is a matter of free choice. When, however, migration is primarily involuntary, where people
588
JOHNB. MCKINLAY
have to move home out of necessity for fear of their lives or because of loss of opportunity of earning a living, different kinds of people may become involved, with quite different consequences for health and subsequent utilization behavior. The differences between voluntary and expulsive or flight migration, for example, may be illustrated by comparing the characteristics of people involved in the ‘brain drain’ movement from the Antipodes to Great Britain, and from Britain to the United States, and the characteristics of those involved in movements from Pakistan to India, North to South Vietnam, or the present Polynesian migration to New Zealand. In the former cases, migration is biased in favor of social groups at low risk to morbidity, while, in the latter three cases, migration probably involves groups of more heterogeneous composition, whose members are at generally higher risk to morbidity and even mortality, with probably quite different disease distributions. The demands on health services from such different groups will also be very different in the host culture. To my knowledge, a distinction has never been made in the literature between the types or nature of migration and subsequent utilization behavior. In the past, researchers have examined the behavior of dzferent populations involved in d@rent types of migration at dierent points in time with, understandably, different (but not necessarily conflicting) results. Since it has been established that specific types of mental illness may be related to specific types of population movement [49-511, it is reasonable to expect that a similar situation may exist with respect to utilization behavior. Some suggestive leads, with regard to the relationship between migration and utilization behavior, are offered in a typology developed for other purposes by Peterson [52] which distinguish between different causes, classes and types of migration. By extending this work to the area of health status and utilization behavior, it may be possible to tease out the pertinent relationships and clarify apparently conflicting findings. MIGRATION,
HEALTH
STATUS
AND
UTILIZATION
BEHAVIOR
Most researchers either directly or implicitly subscribe to the view that utilization behavior is a fairly accurate reflection of the nature and distribution of pathology in a community. This view appears to stem from the somewhat naive, over-rationalized conception of man which suggests that people, in the area of health at least, always act on the basis of self-recognized, role-impairing symptoms. Accordingly, any general increase in service utilization is thought to result from some increase in morbidity in the community, and any decrease is a consequence of some improvement in health status. Such a simplistic model, of course, obscures the complexities of the real situation. With regard to migration, for example, a move to a new location may result in some increase in preventive health behavior (due to the predominant orientation of the medical institution in the new host country) with no obvious change in health status. Similarly, new residents to an area with enduring illness conditions may utilize newly available curative facilities for which there was no comparable service in the country or area of origin. With regard to the relationship. between migration, health status, and utilization behavior, therefore, it may be fruitful to distinguish four distinct situations as follows: (1) The case where there is no alteration in health status and no alteration in utilization behavior;
Some Issues Associated With Migration, Health Status and the Use of Health Services
589
(2) The case where there is no alteration in health status but some alteration in utilization behavior ; (3) The case where there is some alteration in health status but no alteration in utilization behavior ; (4) The case where there is some alteration in health status and some alteration in utilization behavior.* Shuval [53] has recently examined the case where there is no alteration in health status but some alteration in utilization behavior, with a study of a prepaid medical insurance system which serves the majority of the population of Israel, comprising voluntary immigrants. Although the rate of medical care utilization in Israel is one of the highest in the world, existing patterns of morbidity in that country do not adequately account for this phenomenon. The central focus of this rare study of overutilization and migration was on the latent function of the medical system for migrant Israelis, This concern with latent, rather than manifest, functions resulted in a concentration on non-medical needs, of which Shuval isolated five, namely: (1) the need for catharsis or some contact which permits free communication; (2) the need to cope with failure-using illness as a legitimizing mechanism; (3) the need for integration into the social system through contact with a well-established social institution; (4) the need to attain high status through contact with high status physicians; (5) the need for resolution of the magico-science conflict, or for allaying certain health superstitions and affirming modern medical science. Given that one should distinguish between at least the two broad types of migration already referred to (voluntary and involuntary) and the four possible combinations of health status and utilization behavior outlined, a threefold typology can be constructed (see Fig. 1).
Voluntary
I,
H. S. and U. B No change
migration
Involuntary
//l/i// 2. H S No change’ j///j/ ’ ’ ///
/U./B. //
I. H S. and U. B.
(ha”
