Commentary: Migration and health—what about those who stay at home?
1Department of Epidemiology and Public Health, University College London, UK.
2Department of Social Policy, London School of Economics, UK.
* Corresponding author. E-mail: m.bobak{at}ucl.ac.uk
Accepted 18 October 2007
The paper by Burazeri et al.1 is useful for two reasons. First, it draws attention to a largely neglected aspect of migration—health of those who stay at home. And second, it contributes to the enduring debate about the contribution of material and non-material (psychosocial) factors to health. We will discuss these two issues in turn.
First, we consider emigration. The association between migration and health has been a subject of numerous epidemiological studies. A recent review of the literature on internal and international migration identified 362 papers, of which 136 met the inclusion criteria to be included in the final report.2 None of the reviewed papers focused on chronic diseases in those who remained at home. It is understandable that most of the attention focuses on the migrants themselves but even more people are affected by the emigration by their close relatives.
Albania is a good place to study the effects of emigration. In fact, the pictures from 1991 showing Albanian migrants jumping onto boats in an attempt to gain access to a better life across the Adriatic Sea have become a stereotype for describing European migration in the 1990s. What is significant in the Albanian case is the scale of this phenomenon and its tempo. More than a quarter of the Albanian population have left the country since 1990,3 causing a negative population growth and a dent in the age structure of the population. Since emigration affected mainly the reproductive ages, it also had an effect on fertility: the total fertility rate fell below replacement level (to 1.65 children per women in 2005).
While perhaps less dramatic than Albania, many other countries experienced a similar drain of young and economically active people. Anecdotal reports suggest that it is now difficult to find qualified workers in Poland and some other Eastern European countries. Such a massive and relatively sudden exodus affects the labour market and economic conditions of those who remained at home, and it is entirely plausible that the negative consequences include health.
This leads to the second issue—health effects of emigration on those who remain at home. To our knowledge, there is very little research on this important question, especially when it concerns chronic diseases. The results by Burazeri and colleagues suggest that emigration of spouse or offspring is associated with increased risk of acute coronary syndrome, and this increased risk seemed to be largely confined to people whose emigrant family members did not send financial support to home.1 Although case–control studies are known to be prone to biases, the main finding seems robust. Leaving aside the potential interaction with sex, the main question is what is the mechanism of the effects of emigration on health of those who stayed at home.
The authors offer two explanations—financial (material) and emotional (psychosocial) factors, respectively. It will be probably a bit of both.
On the one hand, not receiving financial assistance from those who emigrated has obvious consequences on income and material circumstances of those who stayed at home. Material deprivation is one of the main factors driving emigration. It has been estimated that the amount of money sent home by Latin American migrant workers to their families exceeds the combined total of all direct foreign investment and foreign aid.4 In Albania, it has been estimated that money send from abroad accounted for 14% of GDP and approximately one-third of total household income in 2005.5,6 These are staggering amounts, and it is likely that money from abroad provides the receiving families with a considerable advantage. Despite the difficulties with measuring income (including transfers) and its effects, it is likely that material deprivation caused by the lack of transfers, in this case remittances, has an effect on the health in the population studied.
On the other hand, as Burazeri and colleagues discuss,1 not receiving money from abroad is also a marker of low family cohesion and low social support. There is evidence that major life events requiring emotional adjustment are associated with increased risk of cardiovascular events.7 Emigration of close relatives and the associated loss of social support can have consequences similar to bereavement8 or poor social networks.9 The view that the effects of emigration are not exclusively driven by material factors is supported by the fact that, in this study, adjustment for total household income did not make much difference to the estimated association between acute coronary syndrome and emigration. It is also not clear how exactly would material factors affect cardiovascular risk; classical risk factors are unlikely candidates.
The question as to whether emigration affects health of those who remained at home is an important one, both for research and for public health. If the results are replicated by further studies and in different populations, emigration of close family members may be another interesting social exposure, sharing both material and psychosocial features. Since, in contrast to many other social determinants, this is a reversible exposure, and one which varies over time, it may provide new opportunities to investigate the contribution of different aspects of social environment to health.
Conflict of interest: None declared.
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1 Burazeri G, Goda A, Tavanxhi N, Sulo G, Stefa J, Kark JD. The effects of emigration to those who remain at home. Int J Epidemiol (2007) 36:1265–72.
2 McKay L, Macintyre S, Ellaway A. Migration and health: a review of the international literature. MRC Social and Public Health Sciences Unit, Occasional Paper No. 12 (2003) Glasgow: MRC Social and Public Health Unit.
3 Albanian Institute of Statistics (INSTAT). Main Results of the Population and Housing Census (2002) Tirana: INSTAT Albania.
4 (last accessed on 18 October 2007). http://news.bbc.co.uk/2/hi/business/6465297.stm.
5 Mansoor A, Quillin B. Migration and remittances: Eastern Europe and the Former Soviet Union (2006) Washington DC: The World Bank.
6 Fullani A. Remittances: An opportunity for Growth – The Albanian migration to Italy as a case study (2006) Tirana: Bank of Albania.
7 Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet (2007) 370:1089–100.[CrossRef][Web of Science][Medline]
8 Parkes CM, Benjamin B, Fitzgerald RG. Broken heart: a statistical study of increased mortality among widowers. Br Med J (1969) 1:740–3.
9 Kawachi I, Colditz GA, Ascherio A, Rimm EB, Giovannucci E, Stampfer MJ, Willett WC. A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA. J Epidemiol Community Health (1996) 50:245–51.
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