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Health Equity in a Globalizing EraPast Challenges, Future Prospects$

Ronald Labonté and Arne Ruckert

Print publication date: 2019

Print ISBN-13: 9780198835356

Published to Oxford Scholarship Online: May 2019

DOI: 10.1093/oso/9780198835356.001.0001

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Globalization’s historically defining element

(p.71) Chapter 4 Migration
Health Equity in a Globalizing Era

Ronald Labonté

Arne Ruckert

Oxford University Press

Abstract and Keywords

Migration, the movement of people from birthplace to other-place, whether within their own borders or internationally, is one of globalization’s leitmotifs. The scale of migration has risen rapidly in recent decades, some of it the ‘pull’ of opportunities in other countries, but much of it the ‘push’ of poverty, unemployment, conflicts, and environmental degradations that make life unlivable for many. Migration can improve the health and well-being of migrants, and the remittances sent home by overseas émigrés can contribute to domestic poverty reduction in the countries they leave. But forced migration, migrant exploitation, and increasing barriers to the lesser-skilled irregular migrants or asylum-seekers most able to benefit by moving abroad have given rise to new global imperatives to ‘manage migration’ ethically and effectively. Both men and women may be vulnerable to exploitation along the migratory path, but women face additional gendered discriminations in the risk of assault and trafficking.

Keywords:   migration and health, irregular migration, refugees, asylum-seekers, internally displaced persons, human trafficking, remittances, gendered care chains, xenophobia, managed migration

One in every seven persons in the world is a migrant.

(World Health Organization 2017: 14)

Today, just as happens every day, many thousands of people throughout the world will be setting off on journeys in the hope of being able to forge safe and meaningful lives in a new country. Some will be carrying passports containing visas issued by the country to which they are heading … many others will be setting off on journeys they know will be long and dangerous [knowing] that they may be abused, exploited, or even die en route.

(International Organization for Migration 2018: 171)

Your life depends on a random stranger who could kill you, will probably disrespect you, and most likely will pay you much less than you deserve. But even those prospects are better than the ones you used to have. This is the life of los jornaleros—the day laborers.

(Arellano 2011)

As a global community, we face a choice. Do we want migration to be a source of prosperity and international solidarity, or a byword for inhumanity and social friction?

(UN Secretary-General António Guterres).

(Guterres 2018)

Migration is one of globalization’s defining characteristics and, like globalization itself, has ancient roots. People have long moved from their birthplaces in response to one or a combination of forces: invasion and occupation (the pre-industrial empires of old), forced displacements (the slave trade that accompanied the rise of Western (p.72) European colonialism), economic betterment (Europeans migrating to the Americas and Oceania following the collapse of rural agricultural life), and escape from violence or persecution. Late twentieth and contemporary twenty-first century migrations have similar drivers, but their scale and scope have intensified during our forty year period of hyper-globalization (Subramanian and Kessler 2013), or what this book describes as neoliberal globalization.

Two interrelated phenomena are fueling an accelerating movement of people within and between countries: urbanization and globalization. The former captures the flows of rural agricultural populations to urban centres, around thirty of which have become so large as to be labelled ‘mega-cities’ (over 10 million inhabitants). The top ten of these urban giants have populations exceeding 20 million, with all but one of them (New York City), in Asia (Demographia 2017). Rural populations still outnumber city-dwellers in Africa but urbanization rates there are rising at a faster pace than in any other global region. People are being pulled into cities by employment opportunities, partly an outcome of globalization’s out-sourcing described in the previous chapter and the creation of export processing zones described in the next one. They are simultaneously being pushed out of the countryside by population growth, corporatized agriculture (including forced displacements and ‘land grabs’1), or environmental deterioration in their ability to sustain livelihoods (Foresti and Hagen-Zanker 2017; International Organization for Migration 2018). Nowhere was this migratory ‘push/pull’ more evident than in China’s internal market reforms of the 1980s, which saw hundreds of millions of abruptly underemployed and immiserated peasants leave the countryside for the industrializing cities, a phenomenon with echoes of the European Industrial Revolution (Abel et al. 2018: 60; Duncan and Popp 2018)2 but on a radically truncated time-scale.

The confluence of globalized finance, industrial production chains, and communication technologies creates what Saskia Sassen describes as ‘global cities’ (1991) which, with their concentrations of capital and people, are eclipsing the reach of national policy and regulation (Vezzoli, Villares-Varela, and de Haas 2014), and increasingly shaping migration flows (Schiller and Caglar 2010). At the same time, labour market informalization and employment opportunities that fail to keep pace with population growth, and the inability of governments or private markets to develop the infrastructures needed to keep up with the rural influx, has led to an expansion in ‘slums’ (more politely referred to as ‘informal settlements’) that are now home to more than a billion people worldwide (Cities Alliance 2011). Megacities that continue to enlarge as slums rather than through increased prosperity are poised to become ungovernable—another toxic intersection of globalization and migration, with profound implications for the future health of those living there.

This toxicity exists not only in the internal movements from countryside to city, but in the irregular migration hinted at in our second opening passage, the form that carries the greatest risk to aspiring migrants while incentivizing its criminalization. Our third passage captures some of these risks with journalistic vigour, drawing from one of its major media flashpoints: life along and beyond the US/Mexico border. Its narrative returns us to the metaphor invoked in our first chapter, that of a world increasingly divided into two classes: the tourists and business elites who are free to (p.73) move at will, and the vagabonds for whom border barriers are rapidly rising unless they are ‘deemed … “deserving”, “necessary” or “useful” to help meet wider economic ends’ (Thomas 2016: 5). The wealthier the country, the greater the number of nations its citizens (the tourists) can enter without visa restrictions; the poorer the country, the greater the visa and other entry roadblocks, and the more likely the migration will be irregular (the vagabonds). There are even several countries willing to sell citizenship and all its passport privileges in return for a hefty cash investment within its borders (Richter 2017), an option increasingly enjoyed by corporate oligarchs and corrupt kleptocrats (Pegg, Farolfi, and Orphanides 2017). Many other countries simply make it easy for the foreign wealthy to be welcomed as ‘economic migrants’.

The global class divide, as our final passage argues, is forcing an ever more urgent migratory choice upon us. But as this chapter details, the prosperity often promised by migration, though real for many, may also be illusory for most unless globalization’s disequalizing economic rules and practices are simultaneously and effectively challenged.

Migration by the book and by the numbers

Before interrogating the global political economy of migration, and what it might mean for health, let us first regard its descriptive boundaries. A first consideration is clarifying some of the key terms that populate the migration field. Migration refers simply to people who move within or between states; it can thus be internal (within a country) or international (between countries). Facilitated migration describes efforts to encourage international immigration, often involving streamlined application processes and use of criteria for selection and screening of would-be emigrants. Irregular migration is international migration that takes place outside of normal regulatory norms of sending, transit, and receiving countries. Forced migration arises when there is an element of coercion (such as threats to life or livelihood), conflict, or environmental disasters. Internally displaced persons (IDPs) are those whose forced migration remains within their national borders. The term ‘refugee’ describes individuals who cross borders to escape real or feared persecution, external aggression or foreign occupation, or the serious collapse of public order, and who fall within the mandate of the Office of the United Nations High Commissioner for Refugees (UNHCR), ‘the UN Refugee Agency’. Asylum seekers are persons who seek refugee status under international or national legal instruments. If unsuccessful, they must leave the country unless granted special permission to remain on humanitarian or other grounds, although many may remain in the country as ‘undocumented’ (illegal) migrants. Temporary migrants are people who leave their home country for employment elsewhere on a time-limited basis. Like asylum seekers, some may choose to remain beyond their legal stay as undocumented migrants. Finally, circular migration, of recent coinage, describes the return flow of (particularly temporary) migrants to their home (‘source’) countries.

A second consideration is recognizing that migration by any definitional standard is staggeringly large. Internal migration, most of it rural to urban, numbered at least 763 million in 2013, the last time reliable estimates were made (Bell and Charles-Edwards 2013). International migration is smaller in size, if politically more (p.74) contentious, but in 2017 totalled 258 million, or roughly 3.4 percent of the world’s total population, an increase of almost 100 million since 1990 and a growth rate more rapid than anticipated (United Nations 2017). India, Mexico, and Russia are the top international migrant-sending countries (Foresti and Hagen-Zanker 2017).

Over two-thirds of international migrants fall into the temporary category, most of them moving to high-income countries to pursue employment opportunities: Europe, the wealthy Gulf States, a few Asian nations, some small Caribbean countries, and the Anglo-American quartet of the USA, Canada, Australia, and New Zealand. Most temporary migrants work in the service sector, followed by manufacturing, construction, and agriculture (International Organization for Migration 2018: 29–30). Europe and Asia host the largest number of emigrants, with the Gulf States experiencing the largest increase in temporary labour migrants. Of those seeking permanent immigration, Germany receives the largest number (over 2 million registered in 2015, double the number in 2000), followed by the USA (over 1 million) (International Organization for Migration 2018: 23), although the USA remains the preferred destination country (p.75) for most emigrants. Much international immigration, however, remains regional. About half of African emigrants move within the continent, many drifting southwards towards South Africa, still the region’s economic ‘powerhouse’ (International Organization for Migration 2018: 45). Most Asian emigrants similarly stay within their continental boundaries, although there is a large flow to the USA emanating from China, India, the Philippines, and Vietnam (International Organization for Migration 2018: 85). Repeating the same regionalized pattern, twice as many Europeans migrate within Europe as those leaving the continent (International Organization for Migration 2018: 68), while most South American migration remains intra-regional.

Refugees and asylum seekers, the forced migrants of today’s greatest political consternation, account for one-tenth of the annual cross-border flow of people, or 26 million. Syria in recent years has led the international haemorrhage, with 5.5 million leaving as refugees in 2016 (although many are expected to return if and when hostilities in that country cease), while the annual number fleeing Afghanistan remains high, at 2.5 million (International Organization for Migration 2018: 33). Turkey was the largest receiving country, with close to 3 million (mostly Syrian) arriving in 2016 (International Organization for Migration 2018: 34). While Germany as the lone high-income country in the top ten nations hosting refugees, it is outpaced by countries such as Pakistan, Lebanon, Iran, Ethiopia, and Uganda. Despite images of sardine-packed boats of Africans crossing the Mediterranean for Europe, only 3 percent of displaced Africans seeking asylum each year end up in Europe (Burke 2016). Most remain in Africa, crossing into neighbouring or nearby countries such as Uganda, Ethiopia, and Kenya, with seven of Africa’s least developed countries home to almost 30 percent of the world’s refugee population (International Organization for Migration 2018: 34). With forced migration often involving ‘ethnic cleansing’ or denial of citizenship rights,3 some 10 million international forced migrants are considered to be stateless (Smith 2018).

Adding those who are internally displaced to the number of refugees and asylum seekers yields a total of 66 million people subject to forced migration in 2016, the highest such number on record (International Organization for Migration 2018: 3). Half of these are children. Most IDPs are located in just ten countries, all of which have experienced internal conflicts4 (International Organization for Migration 2018: 37); although the majority of IDPs move due to climate and weather-related disasters, notably those in the southern Asian region (e.g. India, Bangladesh, and Sri Lanka), where ‘migration and mobility have become particularly important coping strategies in response to environmental change events’ (International Organization for Migration 2018: 62). Over 20 million people annually are displaced by climate disasters (Foresti and Hagen-Zanker 2017: 40), with estimates that as many as 1.6 billion people will be displaced by rising sea levels by 2060 (Smith 2018).

Migration’s economic benefits

Current global discourse on migration is dominated by two interlinked themes: ‘managed migration’ (a point we address later) and the ‘migration-development nexus’ (Piper 2017). This latter theme focuses on migration as ‘one of the most successful ways to reduce poverty’ when the flow moves from poorer to richer nations (Foresti and Hagen-Zanker 2017: 108). Receiving countries, in turn, are said to benefit through (p.76) an increase in their working-age population, offsetting their own low fertility rates and ageing demographic. Ensuring adequate protections for migrants during their journeys and after arrival in their new country creates a claimed ‘triple-win’—for source and destination countries, and for migrants themselves. Each of these ‘wins’, however, requires critical interrogation and nuancing.

For source countries, emigration is said to reduce unemployment and underemployment by shrinking the size of the labour pool. Classical (orthodox) economic theory holds that, as the labour pool tightens, competition for workers improves wages and working conditions, such that those remaining behind while others leave for work abroad gain an indirect benefit. Any such benefit, however, assumes that migration outflows are greater than growth in the working-age population, and that employment opportunities continue to outperform labour supply. This is rarely the case, with labour markets in low-income source countries largely informal, offering only dismally-paid and insecure work. In India, the source of over 15 million international migrants annually, over 90 percent of the domestic labour market is informal, consisting primarily of self-employed casual workers (Srija and Shirke 2014) whose living conditions differ little from those ascribed to los jornaleros. While there has been a rise globally in relative income distribution favouring the world’s poorer deciles, with globalization shifting some manufacturing and service jobs from high- to low-income countries, for many internal migrants pursuing employment opportunities in their countries’ swelling cities, the outcome is less a transition out of poverty than poverty’s relocation from the countryside to an urban slum (Schierup, Ålund, and Likić-Brborić 2015; Foresti and Hagen-Zanker 2017), replete with new disease risks associated with crowding, unsanitary conditions, and violence.

Broad-brushed benefits are similarly credited to destination countries, where immigration is argued (sometimes with Panglossian exuberance) as reducing poverty and increasing economic growth through ‘increased productivity, new demand for and supply of goods and services, and more labour-intensive production’ (Foresti and Hagen-Zanker 2017: 101). Several studies support this claim, finding that immigrants often take jobs that are unappealing to native workers, or are more entrepreneurial and willing to work longer hours under harsher conditions. There is also evidence that, over the long-term, immigrants are unlikely to displace the destination country’s labour force unless they are competing for the same jobs at the same skill level (Constant 2014).5 But there are also acknowledged short-term destabilizing effects of such migration on both wages and employment (United Nations Secretary-General 2017), especially in the lower-skilled labour sector. While these downside impacts are predicted to subside after a lag of five to ten years, they often persist for well over a decade. Assuming that there are no recessions that make local employment matters even worse, a continuous inflow of migrant labour can cause employment to lag continuously behind economic growth. As a study synthesizing the recent findings on large-scale immigration at the scale many destination countries are now experiencing concludes, ‘ … the claim that immigrants take jobs from local workers and push down their wages may be exaggerated, but it is not always false’ (Rowthorn 2015: 31). Ironically, the population most likely to suffer adverse wage and employment effects of immigration are themselves earlier migrants (Constant 2014).

(p.77) The other and more pervasive economic argument for open migration is that destination countries need immigrants to ensure an active labour force sufficiently large to stabilize public finances, sustain pension transfers, and provide the health care/home care needed for an ageing population. This assumes that most migrant workers become permanent residents in their new country, which is often not the case, or at least not legally so. More fundamentally, this reasoning is built upon economic modelling of dependency ratios (the proportion of working population to those unemployed or retired), it quickly becomes an endless treadmill, as each new wave of younger immigrant labour itself eventually ages, expanding the size of the top end of the demographic pyramid that then demands ever larger waves of new immigrants to occupy the lower half (Rowthorn 2015).


If classical economics overstates migration’s benefits to source and destination countries, there is one undisputed gain accruing to migrants’ home (source) countries: remittances, the income transferred to families in the home country by migrant workers abroad. In 2017 the estimated value of remittances was US$596 billion globally, of which US$450 billion went to developing countries, an amount three times greater than all forms of development assistance combined. For this reason alone most economists and many development agencies see international migration (whether permanent or temporary) as one of the most important means of global poverty reduction, urging more open (rather than restrictive) migration systems to better harness this effect. There is a large and growing body of evidence finding that remittances can be effective in reducing poverty, especially so for those family members who receive them. There is also a positive, if small, spill-over effect at the aggregate level, likely due to spending of remittances by receiving families that generates tax revenues and local forms of employment (Foresti and Hagen-Zanker 2017: 101). Remittances have also been found to reduce poverty at the household level for non-migrant households, albeit much less so than in families who have a migrant working abroad.

In order of scale, India, China, the Philippines, Mexico, and Pakistan are the top remittance-receiving countries, with total inwards flows to India and China exceeding US$60 billion annually (International Organization for Migration 2018: 45). Several countries receive considerably less in dollar terms, but substantially more as a percentage of their GDP, essentially becoming reliant on remittances for their sovereign survival. Many governments foster temporary or even permanent migration specifically for the value of their émigré remittances; while some development economists even advocate that aid funding to low-income countries should go towards education systems that produce workers with the labour skills wanted by high-income countries, thereby further incentivizing out-migration (Clemens 2014a). Such a proposition might well benefit migrants themselves, while increasing the value of remittances; but it also assumes an endless demand for labour in high-income countries and brackets how increased labour migration could hollow out a developing county’s own nascent middle-class, or accelerate the already documented emptying of rural communities and smaller cities (Root 2006; International Organization for Migration 2018).6 There (p.78) is additional concern that ‘large-scale or specific manifestations of emigration (such as of highly skilled or leadership groups) can have a detrimental effect on a country’s stability’ (International Organization for Migration 2018: 127).

Remittances, while important and a prominent feature of contemporary migration, depend on émigrés remaining in (or circularly migrating in and out of) destination countries while continuing to remit. The extent to which remittances actually lead to economic growth or development in ways that sustain poverty reduction in their source countries depends on the balance between what is spent on familial needs (e.g. education, health, food security, housing) and what goes towards building productive assets (e.g. new businesses or other forms of economic investment) (Boccagni 2017). There is occasional discussion of remittance-receiving countries putting a small taxation on remittances for national development purposes, but the fairness of this has been challenged since taxes on the remittances have already been paid by the émigré worker. A more equitable, if unlikely, policy would be for the destination country to share a portion of taxes paid by migrant workers with their home country governments, assuming the migration was voluntary and not forced due to state or state-sanctioned repression. Finally, despite the value of transnational remittances as a source of social protection for the families that receive them, remittances can weaken the demand for sufficient provisions of public goods and services by governments that have grown reliant on such transfers; that is, remittances can reduce citizen demands for public social protection policies, consistent with the individual ‘responsibilization’ of neoliberalism’s roll-back and austerity dimensions discussed in the previous chapter.7

Migrant gains, migrant losses

International migrants, whether temporary or permanent, often reap substantial economic benefits, with adjusted earnings in host high-income countries at least two to three times greater (in some cases ten-fold more) than what they otherwise earn in their home countries (Foresti and Hagen-Zanker 2017: 99). Internal migrants, those moving from rural to urban centres, also tend to benefit economically, but at a much lower scale. Besides income gains, migrants can also benefit through improved access to educational opportunities and health care, with a recent World Bank report finding that ‘migrants from the poorest countries, on average, experienced a fifteen-fold increase in income, a doubling of school enrolment rates, and a sixteen-fold reduction in child mortality after moving to a developed country’ (Ratha, Plaza, and Ozden 2016: 9). Mortality from infectious diseases and complications of pregnancy and childbirth also decline quickly, relative to rates in their countries of origin (Spallek et al. 2016). These benefits extend primarily to permanent immigrants but, even then, national restrictions often minimize migrants’ eligibility for social protection measures despite their financial contributions to such programmes. Bilateral and multilateral agreements between countries sometimes cover the portability of social protection benefits for temporary migrants, but this applies almost entirely to people moving between high-income countries. Rarely is such protection offered to temporary migrants coming from low-income countries, arising in part from anti-immigrant sentiments; some low- and middle-income countries offset this somewhat with contributory migrant (p.79) welfare funds to assist migrants while working overseas (Spallek et al. 2016: 87), although there are questions about the efficacy and robustness of such programmes.

The pursuit of work may not be the only motivation driving voluntary migration (forced migration is a different matter altogether). People pursuing international migration often cite the desire to create better lives for their children, long one of emigrants’ self-sacrificing determinations; to live in a safer country with more amenities; to assist through remittances family members back home; and, through family reunification schemes, to sponsor parents or other family members to join them in their new country. But the initial ‘pull’ and its accompanying ‘push’ almost invariably revolves around the opportunities migration presents for work (see Box 4.1). For many migrants, however, the initial enthusiasm for work in a new land is quickly dampened by the poor quality of available jobs. For highly skilled immigrants who are often (p.80) encouraged by host countries or recruitment agencies to emigrate, this can lead to a ‘brain waste’ in which they find themselves working below their skill level with limited opportunities for advancement (de Haas, Natter, and Vezzoli 2014). This is sometimes the result of a mismatch between migrants’ particular skills and the labour-market needs of their host country, but also arises from racist, gendered, ethnic, or religious prejudice and social exclusion faced by new migrant groups (Spitzer 2011).

Racialized migrants, particularly women, experience the greatest gap between work in their host country and their level of education and prior work experience (Spitzer 2016). There is also now a deterioration in ‘the healthy immigrant effect’: that those who make the migratory journey are healthier than their peers and, even when moving from poorer to richer countries, generally arrive in better health than the native-born populace. This previous health advantage rapidly fades, as unemployment or underemployment in emigrants’ new countries can lead many families to drift downwards into low-income or even poverty (Spitzer 2016), and appears to be worse for women, especially racialized women.

Matters are much worse for lesser-skilled migrants, especially temporary workers who often face exploitative conditions in their host countries: poor living conditions, limited access to services, low wages (often below that of native workers doing the same job), and poor working conditions. Wages are sometimes less than promised, or not paid at all (International Labour Office 2017a); while temporary migrants are generally bound to a single employer and deterred from organizing or shifting employers, adding to their entrapment within informal labour markets (Foresti and Hagen-Zanker 2017). Migrants are also more likely to work in jobs that are ‘dirty, dangerous, and difficult’ (International Labour Office 2017a), with higher risks of work-related accidents and disease. Much recent attention has focused on the millions of temporary migrants from Nepal, India, and Bangladesh, working on construction sites in the Gulf States. Qatar alone has imported over 800,000 workers to work on its construction projects (Conn 2017), many associated with that country’s hosting of the 2022 FIFA World Cup. Although official figures are hard to come by and often disputed, there are estimates that as many as 1000 migrant workers in Qatar die each year related to their working conditions (Migrant Rights 2017). In the neoliberal terms encountered in the previous chapter, the risks and conditions faced by these migrant labourers might be considered their ‘sovereign’ choice, insofar as the opportunity to work even under exploitative conditions is better than the alternative of entrenched poverty in their home country. This is an argument similarly applied in defense of so-called ‘sweat shops’ in countries such as Bangladesh, described in the next chapter. But it is also one that ignores ongoing global inequalities that drive such Faustian bargains, partly arising from earlier eras of globalization’s more predatory (conquest, colonial) practices or, in the case of the Gulf States as in many older, wealthier nations, the geographic accidents of valued natural resources.

Migration’s gendered face

Women have long been active migrants and today number just under half of all international emigrants, but with large regional variants. In what has been called the (p.81) ‘feminization of migration’, women in many South Asian and Southeast Asian countries (Indonesia, the Philippines, Sri Lanka, and Thailand) comprise the majority of emigrants. They are also much more likely to migrate independently rather than as part of a family system or as dependents (International Organization for Migration 2018: 185).8 Like their male counterparts, female migrants generally experience improvements in their incomes relative to their home country, while remitting higher portions of the earnings and for longer periods back to their families than most male migrants (World Health Organization 2017; International Organization for Migration 2018). The value of these remittances usually factors into women’s decisions to migrate, whether as temporary workers or as permanent residents, and is one that is often made by families as a whole. Young women who leave as temporary workers are more likely to settle and obtain permanent residency in the countries to which they move; older women, especially those who leave husbands or children behind, usually circulate back after a number of years, with agreements between sending and receiving countries often placing a time limit on work abroad.

As with male migrants, a woman’s decision to seek work abroad, even when its attendant risks are known, is seen as an escape from rural poverty and, as such, is frequently portrayed as gender empowering. Emigrating women do experience increased economic agency, as do women whose husbands migrate and send home remittances that they then manage (International Organization for Migration 2018: 185). Women migrants often develop new skills and experience greater freedom of movement and more autonomy. Patriarchal norms can also be disrupted as men who remain find their familial and community roles challenged in new ways by women’s migratory absences (World Health Organization 2017: 54). A recent summary of findings suggests that ‘all things considered … the balance sheet for women [migrants] can be positive, provided migration policies in both countries of origin and destination are formulated with due regard for the particular needs and experiences of migrant women and girls’ (Girard 2017: 59–69).

Note, however, the qualifying ‘can be’ and the requirement for ‘due regard’. The reality for many women migrants is that persisting gender discriminations, compounded by racialized or ethnic and religious prejudices, chip away at the economic gains they might otherwise accrue. Although both men and women migrants are often paid less than native-born workers in the same labour niche, the wage gap for women is greater. This is partly consequent to the gendered segmentation of labour markets that relegates migrants to ‘feminine’ sectors (e.g., health, education, cleaning, cooking, or service industries) which are generally low-paying, considered low-skilled, and ensconced within the informal sector, all of which reduces the economic potential of their migration and its trickle-down health benefits, for both the migrants and those receiving their more paltry remittances. One of the larger and expanding employment categories in which women migrants find themselves is domestic care, frequently in private homes. In 2013, 94 percent of all Sri Lankan female migrants were domestic workers in the Middle East, ‘cooking, cleaning, and caring for children and the elderly’ (de Silva 2018), sometimes working 115 hours per week in a modern-day form of indenture (International Labour Office 2017a: 19–20). Young female migrants in domestic work are especially vulnerable to economic exploitation and sexual violence (p.82) (International Labour Office 2017a: 19–20), a risk that is amplified when such ‘care’ migrants enter through irregular channels via labour brokers’ arrangements with host country employers (the majority of instances), rather than through government-issued visas. Fewer than 15 percent of home-based long-term care workers, as one example, are formally employed (World Health Organization 2017: 36), and it is not uncommon for labour brokers or employers to confiscate women migrant workers’ passports, threaten them with deportation, and prevent them from seeking work elsewhere in the host country (World Health Organization 2017: 38). The reported abuses are not insignificant, and are frequently encountered along the migratory journey as well as in the destination country.

Globalization’s gendered care chains

One aspect of women’s migration that is receiving increased scrutiny is its role in global care chains. Building on the metaphor of global production and supply chains described in the next chapter, the concept of global care chains ‘signifies a failure to address the care gap in destination and origin countries in terms of public service provisioning, using the extraction of care labour from the origin countries as a solution, typically at the expense of migrants’ social needs’ (Piper 2017: 236). Two global phenomena drive the creation of such chains: demographic ageing (more acute in high-income countries) and a lack of, or cutbacks in, public provision of care, consequent to neoliberalism 1.0 (roll-back) and 3.0 (austerity). In parallel, more and more women in high-income countries, along the traditional providers of unpaid care, are entering the labour force, creating a demand for substitute carers. This labour substitution is argued to be one of migration’s positive contributions, with ‘low-skilled immigrant women’ in Italy, for example, providing ‘household services that enable high-skilled native women to spend more time at work’ (Constant 2014: 8). Setting aside the often questionable assumptions about skill-levels (many migrant women arrive with higher educational attainments than the native population), immigrant care-givers often have their own children and husbands that are left behind. The care once provided by those who have left is, in turn, substituted by aunts, grandmothers, other relatives (usually women) or paid caregivers, using some of the remittances sent home. Elder daughters or related adolescent girls from rural households often take up the tasks vacated by the migrant mother, compromising their own future education or employment opportunities (World Health Organization 2017: 50).9

As the number of migrant care-givers rises, it is creating a ‘care drain’ within many source countries, offsetting remittance benefits while inducing negative health impacts, notably psychological stress amongst the remaining family members and migrant women themselves (World Health Organization 2017: 35). Separations between migrant care-workers and their children, who are often young when they leave, can last for ten to fifteen years or longer. Although digital technologies are transforming what were once called Diasporas into ‘transnational communities’ of concurrent connectivity, allowing for a degree of ‘transnational parenting’ (World Health Organization 2017: 50), ‘family members at both ends of the global care chain often cannot afford landlines or cellphones, much less computers’ while live-in care-givers may be (p.83) denied access to cellphones or laptops by their employers (World Health Organization 2017: 49).

Emigrating women are often viewed in their source countries as ‘heroes’ (or heroines) for the sacrifices they make in return for the economic benefits their work abroad creates. The emotional suffering that émigré mothers experience is worn ‘almost as a “badge of honour” symbolizing their commitment to their families’ (World Health Organization 2017: 54), as they are caught in the ambivalent space of regret over family loss and pride over an ability to provide financially for their families. Over a quarter of a century ago, feminist philosopher, Joan Tronto, argued that ‘Care is not … a type of secondary moral question or the work of the least well off in society. Care is a central concern for human life. It is time we begin to change our political and social institutions to reflect this truth’ (1993). Global care chains, at least as presently configured, represent the failure of such institutions to do so.

The plight of the refugee/asylum seeker

The number of people forced to move is rising rapidly. Most do not flee far; and their future prospects, even when given refugee status under international law, are depressingly few. There are three so-named ‘durable solutions’ to the refugee ‘problem’: repatriation to their home countries after the conflicts or persecution subside; integration into the host country; or resettlement in a third country (Meyer, Bennouna, and Stark 2016). None of these solutions are working well. Conflicts and persecutions often persist for decades in the countries from which refugees flee, and added environmental degradation and the difficulties in rebuilding ruined villages decreases the likelihood of return. Most host countries, the often poor contiguous nations of ‘temporary’ refugee housing, face their own population and economic pressures to which they would rarely embrace adding millions more.

Resettlement can be the most successful durable solution, with countries agreeing to accept a certain number of UN-designated refugees annually, the USA, Canada, and Australia being the top-ranking resettlement countries. But less than one percent of refugees are resettled under such agreements (Meyer, Bennouna, and Stark 2016), with around one-third of the world’s refugees living in quasi-permanent settlements in which many are being born and are likely to die. Over half of these camp residents are women and 60 percent are children (Meyer, Bennouna, and Stark 2016). Health care, food, nutrition programming, and education are generally provided by international relief agencies, but the funding gap between what is needed and what is provided is growing larger (United Nations Office for the Coordination of Humanitarian Affairs 2018). Although some host countries allow refugees to leave these camps and to work in the local area, effectively becoming ‘permanent refugees’ with often only limited access to health care or other social protection services (Foresti and Hagen-Zanker 2017: 31), other countries restrict them to what become de facto informal prisons, or exclude them from formal employment, increasing their risks of exploitation in the informal economy (see Box 4.2), including their capture into criminalized trafficking networks.


Dispersed refugees face worse communicable disease risks than those in managed camps, which usually have better disease control measures. But the UN Refugee Agency (UNHCR) recognizes that protracted internments in such camps still increases such disease risks for all the well-known proximate causes: over-crowding, lack of potable water, poor sanitation, and inadequate nutrition leading to acute hunger (Foresti and Hagen-Zanker 2017: 31). Infant and child mortality rates are particularly high, even if they may be better than those in the conflict or disaster regions from which they fled. Overall mortality rates amongst refugees, however, tend to be higher than those in the countries in which they find themselves. The post-2015 and, as of writing, still ongoing Yemen civil war so far has created almost 300,000 UNHCR-designated refugees, while displacing almost 2 million more (Norwegian Refugee Council) leading (p.85) to the worst cholera outbreak in human history. Female refugees (both in camps or internally displaced) face sexual violence, with rates estimated as high as 20 percent (Foresti and Hagen-Zanker 2017: 31). Only in recent years has attention been given to the mental health trauma experienced by most refugees, including post-traumatic stress syndrome, although criticisms have also been made of the Western nosologies that can dominate interventions, ignoring cultural differences in mental health interventions and sometimes aggravating rather than alleviating the psychological distress (Foresti and Hagen-Zanker 2017).

Just as residents (with or without outside assistance) attempt to upgrade slums that arise from internal migration, refugee camps sometimes become organized ‘cities’ unto themselves. An oft-cited example is Dadaab in Kenya, whose 300,000 plus refugees make it the largest such camp in the world (Foresti and Hagen-Zanker 2017: 62). Restrictions or difficulties in leaving the camp led residents to create their own small businesses ‘from bakeries to boutiques providing services, products, and a ready market for locals as well as a substantial tax return to the Kenyan government’ (Hujale 2016). Not all such camps fare as well, and the sustainability of Dadaab rests on ongoing international assistance. It does offer a sliver of optimism in an otherwise desultory future facing most refugees, especially those seeking asylum and awaiting some adjudication of their refugee claim.

Australia, one of the main refugee resettlement countries, began outsourcing its processing of asylum seekers in 2001 to privately-run detention camps in two other countries: Manus in Papua New Guinea (PNG), and the small island nation of Nauru, both dependent on Australian aid transfers (Sparrow 2016). To deter asylum seekers arriving by boat from Asia, and to redirect them to these offshore centres, the country in 2013 further decreed that no person arriving directly by boat would be resettled in Australia. Documented conditions in these out-sourced processing camps subsequently generated considerable outrage over incidents of physical and sexual violence, and an eventually-settled class action lawsuit (Wyeth 2017). The Manus detention camp was later closed, having been ruled unconstitutional by the PNG Supreme Court. In an unusual agreement, the USA (under the Obama Administration) agreed to resettle Australia’s Manus and Nauru asylum seekers in exchange for Australia resettling a similar number of Central American asylum seekers detained in US detention camps (Cave 2018). As a stop-gap measure this may help affected individuals, but hardly ranks as a ‘durable solution’. Australia is not alone amongst countries in creating ‘prisons’ for people whose only crime is a desire to leave unlivable conditions, an escalating global phenomenon that is behind the international push for a ‘managed migration’ solution.

Conclusion: managing migration

One of the most compelling images of modern-day migration is that of the desperation of peoples from Latin America, Africa, the Middle East (most recently Syria and Afghanistan), and parts of Southeast Asia taking extreme risks under criminalized and unsafe conditions to seek refuge or simply a better quality of life in another country. Whether counted as ‘forced’ or ‘irregular’ migration, rarely are such journeys (p.86) undertaken idly. In the stark impressions evoked by a young Kenyan-born Somali poet living in London:

No one leave home unless / home is the mouth of a shark.

You only run for the border / when you see the whole city / running as well.

No one puts their children in a boat / unless the water is safer than the land.

(Bausells and Shearlaw 2015)

Since 2000, more than 46,000 migrants have died along their journey, the largest numbers on the trek to North Africa and then across the Mediterranean. Locals on the islands or shores on which those who survive such crossings land face the challenge of their absorption or transition, as their governments turn increasingly to militarized means to stem the flows. It is the pressures emanating from forced, asylum-seeking, and irregular migration that is accelerating an almost commensurate desperation globally for some way to ‘manage migration’ for the triple-wins (for source and receiving countries, and for migrants and their families) that migration is often claimed as offering but less frequently found to be delivering.

Migration’s wage differences and relative income gains are greatest for lower-skilled workers, the very vagabonds whose migration movements are becoming increasingly restricted. These restrictions are buttressed by a growing xenophobic rhetoric that, although rarely the majority voice of a country’s population, is being politically manipulated by a very loud minority. Media coverage of immigrants in high-income destination countries now outpaces favourable coverage two to one (World Health Organization 2017: 193). Partly explained by the media adage that good news is no news, such negative imaging nonetheless is blamed for Australia’s eventual decision to offshore its processing of asylum seekers, and appeared to be a deliberate choice to counter government efforts in the late 1970s to humanize the depiction of such would-be refugees (Doherty et al. 2014). Similarly overblown are the threats of refugees being terrorists. Although this possibility exists, over a forty year period (1975–2015) the risk of an American being killed by a foreign-born terrorist or radicalized refugee was less than one in 3.6 billion a year (International Organization for Migration 2018: 217). Despite such evidence, and as the World Health Organization warns, ‘We are witnessing unprecedented levels of xenophobia, racism, and sexism against migrants’ (World Health Organization 2017: 16).

So enters a policy discourse and new set of UN-level initiatives ‘to manage large movements of refugees and migrants in a humane, sensitive, compassionate, and people -centred manner … through international cooperation’, all the while addressing ‘the root causes of large movements of refugees and migrants’ (United Nations General Assembly 2016: 11–12). The lengthy 2016 New York Declaration for Refugees and Migrants from which this passage is taken was the highest-level UN meeting ever convened on global migration. It is replete with similarly noble-worded sentiments, leading one group of migration researchers to comment that ‘an ostensibly emerging global governance regime for migration is … littered by conventions and declarations, which have mostly failed to impact on real politics and policies in national contexts’ (Schierup, Ålund, and Likić-Brborić 2015: 7). There are already several existing human rights covenants and conventions specific to migrant workers, including on (p.87) social security protection and, for domestic workers, their right to ‘decent work’. Such soft-law covenants, however, are difficult to enforce, a point to which we return in chapter 16,10 not all countries have ratified them, and many nations have contradictory migration interests, simultaneously being a source, transit, and destination country.

The next iteration of efforts to improve migration governance is to use the New York Declaration, nominally agreed to by 193 nations, to create a Global Compact on Migration. The core agreements such a Compact would have member states commit to include:

  • Protecting the safety, dignity and human rights, and fundamental freedoms of all migrants, regardless of their migratory status, and at all times;

  • Supporting countries rescuing, receiving, and hosting large numbers of refugees and migrants;

  • Integrating migrants—addressing their needs and capacities as well as those of receiving communities—in humanitarian and development assistance frameworks and planning;

  • Combatting xenophobia, racism, and discrimination towards all migrants (International Organization for Migration 2017).

The Compact will articulate non-binding principles and voluntary guidelines, a form of problematic soft-law, since global rules regulating the cross-border flow of goods, services, and capital (our globalized economy) come with enforcement penalties, while those governing the flow of people do not. It would be naïve to dismiss the potential normative (persuasive) value of a Global Compact on Migration, but ingenuous to think that, in itself, it would make much of a difference.

Managed migration strategies are most optimistically seen as reformist attempts to minimize or eliminate the exploitative conditions of irregular migration, and the lack of coherence between outward labour flows and the skills needed by inward receiving countries. To the extent that managed migration policies succeed in protecting emigrants along their migratory paths, and in increasing the income transfers (via remittances) from richer to poorer nations, they may even reduce some of the ‘push’ drivers of migration. Variously described as ‘mobility transition’ or the ‘migration hump’, emigration outflows rise with increases in GDP/capita at the low-end of the scale (since poor individuals need a certain amount of income before being able to act on their migratory intentions) before peaking and then tapering off as domestic employment options and improved livelihoods improve. This peak occurs at between adjusted (purchasing power parity) $6000–8000 GDP/capita (Clemens 2014b), the level achieved in upper-middle-income countries and one that is also associated with life expectancy outcomes similar to those achieved in much wealthier nations. But, as we explore further in chapter 7, the world remains far-off in achieving such globally equitable income gains.

At the same time, managed migration can also be seen as a way of continuing a neoliberal individualization of global inequalities (certainly as existing between states, if not also within them), and of ensuring that labour flows are disciplined to meet market needs and expectations rather than human needs or cosmopolitan notions of global citizenship. Yet efforts such as the Global Compact on Migration to create norms (if (p.88) not rules) for fairer and healthier protections for ‘people on the move’ can also be interpreted as a partially articulated form of global citizenship, and one implicitly called for within several of the new Sustainable Development Goals discussed in later chapters.

For the moment, we close with the UN Secretary-General’s optimistic charge to the world’s nations grappling with (if too often stumbling over) one of globalization’s most iconic and defining elements:

… this is not solely a matter of States, but of peoples. The Universal Declaration of Human Rights reminds us that ‘all human beings are born free and equal in dignity and rights’. Today, one of the single most fundamental determinants of the capacity of individuals to realize their full potential and rights is their place of birth. Some are born into opportunity and others into deprivation. Migration, properly managed, is a route for individuals to make the most of their lives, and achieve the dignity that our predecessors enshrined in the Universal Declaration. Their quest for equality is a legitimate one. The global compact should ensure that they can pursue it in a safe, orderly and regular manner.

(United Nations Secretary-General 2017: 20)

MigrationGlobalization’s historically defining element

Figure 4.1 International Migration Report 2017: Highlights

Reproduced with permission from United Nations, Department of Economic and Social Affairs, Population Division (2017). International Migration Report 2017: Highlights (ST/ESA/SER.A/404). Copyright © 2017 United Nations.


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(1.) See chapter 12 for more details on ‘land grabbing’ and its potential health implications.

(2.) The push/pull metaphor will figure prominently in chapter 9’s discussion of a specific form of global migration, that of skilled health workers.

(3.) The minority Muslim Rohingya in the majority Buddhist Myanmar state of Rakhine now fleeing into neighbouring Bangladesh is a recent example. It also attests to migration (facilitated or forced) as legacies of colonialism. During British rule over the area that today includes Pakistan, India, Bangladesh, and Myanmar (1824–1948), there was frequent internal migration of labourers, including Rohingya moving from the Bengal regions of India (now Bangladesh) into the Rakhine region of Myanmar. Post-colonial independence allowed old enmities based on religion and ethnicity to surface with violent conflicts initiated by both Rohingyan nationalists and the Myanmar armed forces (Human Rights Watch 2010).

(4.) The ten countries with large IDP populations are Colombia, Syrian Arab Republic, Sudan, Iraq, Democratic Republic of Congo, Yemen, Nigeria, South Sudan, Ukraine, and Afghanistan.

(5.) One such study found no correlation between immigration and employment rates for seventeen Organization for Economic Co-operation and Development countries, although the time period chosen (2001–2007) is a little odd, if not somewhat suspect, given rising economic growth rates in these countries over this period that were then followed by negative growth and rising unemployment consequent to the 2008 financial crisis and ensuing recession (Constant 2014).

(6.) When applied to skilled health workers, this argument could be construed as partial compensation for the investments governments have made in training health workers who then migrate to high-income countries, an argument we ourselves have made in the past (Labonté, Packer, and Klassen 2006). Such a practice could ensure a supply of health workers who remain in their home country. Chapter 9 returns to this point and, while not resolving it, argues that any such financial transfers for the loss of skilled workers should not be considered part of a high-income country’s development assistance (aid) contribution but rather as part of bilateral financial agreements specific to training of potential skilled migrants.

(7.) Responsibilization is a term developed in the mid-1990s to describe processes whereby citizens become individually responsible for tasks previously undertaken by others, usually a (p.89) government agency. It is associated with the rise of neoliberalism and entrenchment of previous welfare entitlements, and has been studied across most spheres of civil life, such as policies that incentivize or enforce private savings for pensions or the purchase of private health insurance, to increased private costs of education and promotion of private security over public policing (Wakefield and Fleming 2009).

(8.) Some of the women seeking asylum in another country do so to escape gender persecution. An analysis of female refugee claimants in Canada between 2013 and 2017 found that around 5000 claimed different forms of gender-based violence, ranging from domestic violence and forced marriage to female genital mutilation. Over half the claims were accepted, but large numbers of women were returned to countries and families where their personal safety is at risk (Pauls 2018).

(9.) One of us was once approached by a frustrated European advocate for aged care whose idea was to create retirement homes in sub-Saharan African countries where elderly Europeans could avoid the continental winters and be cared for by African providers who would then be less-distanced from their own families. At another time he met a physician entrepreneur in a low-income country keen on medical tourism who had similar if more ambitious plans to develop a rural community with its own health professional schools, hospital, retirement village, assisted care village, and golf course, with a keen eye to the European and North American retiree market. Neither plans prima facie seem feasible, but they both speak to how globalization is transforming how flows between countries are even being considered.

(10.) The normative force of the ‘soft-law’ (non-binding) Convention on Decent Work for Domestic Workers nonetheless led several countries to reform their own labour laws, making the rights inherent in the Convention enforceable within their own national court systems.