IJE Advance Access originally published online on November 19, 2007
International Journal of Epidemiology 2007 36(6):1273-1274; doi:10.1093/ije/dym223
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Commentary: Kisses or money for Penelope?
Department of Epidemiology & International Public Health, Bielefeld University, School of Public Health, P.O. Box 100131, 33501 Bielefeld, Germany. E-mail: oliver.razum{at}uni-bielefeld.de
Accepted 9 October 2007
Migration can be hazardous to the health of those who leave their home, a fact well known since ancient times. Odysseus, the archetypical wanderer, migrated from Ithaca to Troy, where he found employment in the fields of construction (of a wooden, horse-shaped contraption) and demolition (of cities). The jobs were risky, and mortality among his fellow migrants was high. Odysseus survived, thanks to his wit and courage.1,2
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After completing his task and making some money Odysseus headed back home towards Ithaca. Return migration poses its own risks, as he and his companions were soon to learn. Storms, an ill-disposed Cyclops, the man-eating Laistrygones, the Sirens, as well as Scylla and Charybdis, took a heavy toll. A charming nymph by the name of Calypso almost convinced Odysseus that there can be sweeter pleasures than home. But he could not forget his native land and continued his voyage, reaching Ithaca shipwrecked and desolate, two decades after his departure.1
Homer reports in much detail on Odysseus’ travels and the health hazards he faced. The epic provides us with hardly any information on the health of Odysseus’ wife Penelope who remained back home in Ithaca, looking after the house and their son Telemachus. For 20 years, she did not have a clue whether she would ever embrace and kiss her husband again. Odysseus never sent money back home, and the longer his absence lasted, the harder Penelope had to struggle to keep the house in order and to maintain her place in society.1
Homer's focus on the migrants and the health hazards they faced, rather than on the health and well-being of their relatives remaining behind, is reflected in today's migrant research. The health of migrants has frequently been studied, but rarely ever that of the spouses and children they leave behind. Genc Burazeri from Albania and his colleagues aim to fill this gap. In this issue of the journal they report on cardiovascular risk in the context of migration—not on the risk experienced by migrants leaving Albania, but on the risk faced by their non-migrating relatives who remained in the home country.3
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Burazeri et al. conducted a case-control study in which they investigated the associations between emigration of a close family member, financial remittances sent back by the emigrants, sex and acute coronary syndrome (ACS) among non-migrating family members in Albania. The authors make two claims: First, that they may have identified emigration of a close family member—in particular of a husband—as a novel independent risk marker for coronary heart disease (CHD). Secondly, that the resulting risk is attenuated if the emigrant sends back remittances.
Given the abundance of studies claiming to have identified new risk markers for CHD, some caution seems appropriate.4 Have similar findings been reported? In the absence of studies looking at the health of emigrants’ relatives, other scenarios of separation could be assessed. They would have to reflect the breakdown of social support and the failure to cope with stress presumably experienced by the relatives. An extreme example is the death of a spouse. Bereavement is known to have a measurable effect on mortality and on CHD risk, but only for a relatively short time period (6 months to 2 years).5,6 Burazeri et al. unfortunately did not examine whether time since emigration had an effect on CHD risk. And while in Burazeri's study, an increase in CHD risk was experienced predominantly by women, excess morbidity and mortality after bereavement tends to be highest among men.5,6 Thus, alternative explanations for the findings of Burazeri et al. such as residual confounding by socioeconomic status cannot be ruled out: as in many other places, well-off women in Albania might have a lower CHD risk than their disadvantaged sisters.
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The most striking finding in this article is the attenuation of an excess CHD risk among relatives by remittances received from the emigrants. The authors speculate that ‘non-remittance of funds might be perceived of as lack of caring (i.e. absence of emotional support)’. This is a strong statement. Taken to the extreme, it implies that love alone is not good enough—or worse, that embraces and kisses can be replaced by remittances.
Again, there is reason for caution. The variable ‘financial remittance’ is neither properly defined nor quantified in this study. ‘Remittance’ could thus mean anything from small amounts of money sent back only once, at irregular intervals, or for a short period of time, to substantial sums sent regularly over many years. Following the authors’ line of argument, there would have to be a discernible gradient in ACS risk with size and regularity of remittances. As long as this has not been shown, residual confounding by socioeconomic status should again be considered as an alternative explanation.
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Odysseus found no opportunity to kiss Penelope for 20 years. He never sent her money and even lost all his booty on the way home.1 Globalization and new technologies have since helped to improve the lives of migrants and their families. Money can now be transferred safely and quickly around the globe. But it is too early to conclude that all will be well in terms of the health of family members as long as emigrants send back remittances: The role of direct emotional support—exemplified by kisses—has not as yet been studied. With short travel times, low airfares and transnational families, some of today's migrants and their families have found ways to reunite more often than Odysseus and Penelope.7 Thus, the study population of Burazeri et al. presumably includes migrants who see their family on a regular basis. If these were largely the same ones who are also sending remittances, the lower CHD risk may in fact be due to more frequent visits home. Until additional evidence has been produced, money should not be given preference over kisses.
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References |
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1 Homer. The Odyssey (1997) London: Penguin Classic.
2 Homer. The Iliad (1999) London: Penguin Classic.
3 Burazeri G, Goda A, Tavanxhi N, Sulo G, Stefa J, Kark JD. The health effects of emigration on those who remain at home. Int J Epidemiol (2007) 36:1265–72.
4 Davey Smith G, Ebrahim S. Data dredging, bias, or confounding. They can all get you into the BMJ and the Friday papers. Br Med J (2002) 325:1437–38.
5 Martikainen P, Valkonen T. Mortality after the death of a spouse: rates and causes of death in a large Finnish cohort. Am J Public Health (1996) 86:1087–93.
6 Biondi M, Picardi A. Clinical and biological aspects of bereavement and loss-induced depression: a reappraisal. Psychother Psychosom (1996) 65:229–45.[CrossRef][Web of Science][Medline]
7 Razum O, Sahin-Hodoglugil N, Polit K. Health, wealth, or family ties? Why Turkish work migrants return from Germany. J Ethnic Migration Studies (2005) 31:719–39.[CrossRef]
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