UCSD Division of Global Public Health in association with the Center for Comparative Immigration Studies

Director: Steffanie Strathdee, Ph.D.
Co-Director: Wayne Cornelius, Ph.D.

ABSTRACT

The mission of the Center of Expertise on Migration and Health (COEMH) is to provide leadership to improve health and eliminate health disparities of international migrants, refugees, and internally displaced people around the world. Serving local, national and international communities, we will seek new knowledge to forge sustainable improvements in the health of migrant and refugee populations through basic and action-oriented research, policy analyses, applied learning opportunities, and innovative dissemination activities. To accomplish these objectives we will draw upon multidisciplinary scholarship from all University of California campuses. Building upon our expertise on immigration from Mexico and Asia, we will explore migration and health issues in all regions of the world.

The COEMH will be the only world-class, truly cross-disciplinary research and training center on population mobility and health. It will bring together three groups that have seldom interacted in a sustained way: social scientists specializing in international migration, bio-medical/public health researchers and practitioners, and legal and human rights scholars. THE COEMH will pursue a multi-method, multi-level research approach, collecting individual-level qualitative and quantitative data through community-based studies, integrating the findings of such studies with large-scale socio-demographic data sets. Special attention will be devoted to generating new, primary data sets and conducting longitudinal research to elucidate causal mechanisms.

The COEMH will provide hands-on, action-oriented learning experiences related to migrant health issues will be provided to all students participating in its programs. This will be accomplished through fieldwork placements in migrants’ communities of origin and destination as well as NGOs and public agencies that interact with immigrant and refugee populations. In all of its research, training, and dissemination activities, the COEMH will systematically pursue opportunities for transnational collaboration between UC and internationally-based researchers. The Center will use its partnerships with global communities and organizations to translate research into effective, culturally appropriate practices and sound programmatic interventions, using advanced media and distance-based information technologies for dissemination.

The Center’s research agenda will focus on four key issue areas: behavioral and socio-economic determinants of health, health outcomes in migrants’ communities of origin and destination, child health, and health care delivery and policy. Forty scholars at nine UC campuses have agreed to serve as the COEMH’s initial core faculty.

MISSION STATEMENT

The mission of the Center of Expertise on Migration and Health (COEMH) is to provide leadership to improve health and eliminate health disparities of international migrants, refugees, and internally displaced people around the world. Serving local, national and international communities, we will seek new knowledge to forge sustainable improvements in the health of migrant and refugee populations through basic and action-oriented research, policy analyses, applied learning opportunities, and innovative dissemination activities. To accomplish these objectives we will draw upon multidisciplinary scholarship from all UC campuses. Building upon our expertise on immigration from Mexico and Asia, we will explore migration and health issues in all regions of the world. The Center will implement graduate education, conduct research in migrant and refugee communities, establish distance education opportunities, and develop transnational collaborations. These activities will provide a rich, real-world environment for training the next generation of leaders who will respond to emerging health issues related to migration. Our efforts will be informed by basic principles of social justice and human rights as they apply to migrant and refugee populations. The COEMH will use its partnerships with global communities and organizations to translate research into effective, culturally appropriate practices and sound public policies.

KEY INNOVATIONS

The COEMH will be transformational in the following ways:

• It will be the only world-class, truly cross-disciplinary research and training center on population mobility and health.
• It will bring together three groups that have seldom interacted in a sustained way: social scientists specializing in international migration, bio-medical/public health researchers and practitioners, and legal and human rights scholars.
• It will pursue a multi-method, multi-level research approach. The COEMH will collect individual-level qualitative and quantitative data through community-based studies, integrating their findings with large-scale socio-demographic data sets. Special attention will be devoted to generating new, primary data sets and conducting longitudinal research to elucidate causal mechanisms.
• Hands-on, action-oriented learning experiences related to migrant health issues will be provided to all students participating in COEMH programs. This will be accomplished through fieldwork placements in migrants’ communities of origin and destination as well as NGOs and public agencies that interact with immigrant and refugee populations.
• In all of its research, training, and dissemination activities, the COEMH will pursue opportunities for transnational collaboration between UC and internationally-based researchers.
• The COEMH will emphasize dissemination and translation of research findings into policy and programmatic interventions and general public education, using advanced media and distance-based information technologies.

RATIONALE

Population movements have emerged as a major risk factor for chronic and infectious diseases. Migrants face significant barriers to accessing timely and affordable health care. Populations displaced, either within their own countries or across international borders, also typically suffer from risks to safety and reproductive health and from disruption of livelihoods with resultant food insecurity and malnutrition. Migration is a global phenomenon, with nearly 200 million people (3% of the world population) living outside the country of their birth. Voluntary migration is predicted to accelerate globally in the next several decades as a result of climate change, with the United Nations estimating there will be 50 million “environmental refugees” by the year 2050, i.e., persons who will leave land no longer tenable for living due to drought, floods and extreme weather events. The University of California should be a global leader in addressing the health issues posed by worldwide population movements, working closely with programs around the world to improve the health of all people on the move.

The COEMH will focus particularly on health issues facing the one in four Californian adults and children who are foreign-born — including economic migrants, refugees, and asylum-seekers — and how their health status impacts that of native-born Californians. The state’s foreign-born population increased more than five-fold between 1970 and 2006, yielding a much higher proportion of immigrants (27%) than the nation as a whole (13%). Among native-born Californians, more than one out of five has at least one immigrant parent. Immigration will account for 40% of California’s population growth in the current decade. Many of California’s immigrants and refugees have special needs that are compounded by a lack of health care insurance. At least 2.4 million uninsured non-citizens under the age of 65 reside in California. Latino immigrants are at increased risk of HIV and TB and have a higher incidence of diabetes and job-related injury compared to other demographic subgroups. Addressing these needs is critically important to creating an inclusive, cost-effective health care system for the 21st Century, and to reducing risk factors for adverse health outcomes through effective, population-based prevention programs. Many of the lessons garnered through U.S.-based research have implications for efforts in other parts of the world and vice versa. The COEMH can play a global leadership role in assuring a two-way flow of information about policies, practices, and scholarship for a variety of decision-makers.

Extant research suggests that the health status of immigrants varies by country of origin and the circumstances surrounding migration (e.g., voluntary vs. forced migration). Many immigrants originate from countries with lower life expectancies and worse health outcomes than the U.S., but upon arrival in this country they are healthier on many measures and have lower mortality than native-born populations, raising questions about selectivity in immigration flows. However, the health status of immigrants and their children tends to deteriorate with longer residence in the U.S. For example, researchers have found that the odds of some risky health behaviors (e.g. smoking, substance abuse) increase with time lived in the U.S. All this suggests the need for further, multi-method research to explain the complex inter-connections of migration, behavior, and health. Moreover, comparative studies are needed to ascertain whether these patterns occur in other migrant groups in both developed and developing countries. For example, COEMH researchers might conduct comparative research on Karen tribes living in Thailand and in Fresno. Finally, given ongoing public debates concerning the human services impacts of immigration, it is important to conduct comparative, policy-oriented studies to ascertain how other countries have or have not provided health care services for immigrant and refugee populations.

RESEARCH AGENDA

The COEMH’s research agenda will be cross-national, cross-regional, and cross-disciplinary. Affiliated researchers with expertise in demography, other social sciences, epidemiology, medicine, and health care systems in other countries will compare migrant health indicators, public health policies, and policy outcomes in California with those of other U.S. regions and foreign countries. Special attention will be devoted to the following four areas of research, in which the COEMH’s affiliated faculty have particularly deep expertise:

• Behavioral and socio-economic determinants of health: Industries with high densities of migrant workers, like agriculture and construction, present special occupational health hazards. The COEMH will study the policy and socio-cultural factors that shape work-related behaviors, helping regulators and service providers reduce migrants’ high rates of occupational injuries and disease. Similarly, local communities in which migrants and refugees settle play an important role in shaping health status and access to care. For example, immigrant-dominated communities tend to have a higher incidence of environmental health risks and more limited availability of health care, including mental health services. Moreover, immigrant and refugee groups vary in their processes of social, economic, and cultural incorporation into destination societies, which can affect health behaviors and outcomes in both positive and negative ways. The COEMH will seek to explain these variations and develop appropriate intervention strategies that can be tested in various contexts.
• Health outcomes in communities of origin and destination: Migration is a dynamic process including multiple stages (departure, border crossing, arrival, return) which impact both the communities of origin and destination in complex ways. The COEMH will study the transnational epidemiology of chronic and infectious diseases in immigrants’ places of origin and destination. Infectious diseases are not limited by national borders. Improving our understanding of the role of migration and poverty-related characteristics in the transmission of infections is key to developing policies that make both migrants’ communities of origin and destination healthier. The COEMH will study the impact of specific government interventions on international migration flows and disease transmission and treatment, with special emphasis on infectious diseases such as HIV, other sexually transmitted infections (STIs), and tuberculosis. We will also study the impact of migration on chronic health conditions like diabetes, both in their country of origin and destination.
• Child health: Well over half of California’s children are either immigrants or the children of immigrants – a much higher percentage than in the U.S. as a whole. In Los Angeles, for example, 62% of children have at least one foreign-born parent. Most children of immigrants are U.S. citizens by birth but may be at risk due to their parents’ immigration status and socioeconomic level. Many of these children (14%) have at least one unauthorized immigrant parent. Such “mixed-status” families pose special challenges for health care delivery, since unauthorized immigrant parents may be reluctant to approach U.S. health service providers. Children’s health can also be compromised by low family incomes, lack of education, poor nutrition and food insecurity (leading to premature obesity and higher risk of diabetes), and a lack of preventive care. We will devote special attention to this vulnerable subpopulation of immigrants and refugees.
• Heath care delivery and policy: By increasing our understanding of the barriers migrants face in access and utilization of health services, we can reduce public health risks in entire communities. The COEMH will systematically address the impacts of migrant/refugee status, ethnicity and socioeconomic status on health service utilization, including patient-provider communication regarding sensitive issues. Numerous public health issues are transnational in character, including the market for medical coverage and the transmission of infectious agents. By deepening ties between migrant-sending countries and experts within California, the COEMH can generate data that facilitate development of policies whose effectiveness is unconstrained by national political and administrative barriers. The COEMH will demonstrate how health care policies and practices directed at immigrants can be improved through transnational research, health promotion activities, and program design and implementation.

CURRICULUM

The COEMH will offer a range of educational and degree opportunities for students at various levels. These will initially include a Master’s (and eventually, a PhD degree) in Global Health, with a focus on Migration and Health; certificate programs for undergraduate and postgraduate trainees; short-term training opportunities for Master’s Degree students from developing countries; and continuing education opportunities for professionals. The interdisciplinary degree will draw upon disciplines from many UC Schools and Departments (e.g., political science, anthropology, ethnic studies, area studies, sociology, epidemiology, psychology, medicine, environmental health, public health, health services, geography, law, linguistics, ethics, and policy). We anticipate that all enrolled Global Health students will be exposed to principles pertaining to migration and health as part of their core curricula. However, students who select Migration and Health as their area of concentration will develop a tailored program in their studies and core competencies.

Curricula will be developed by the Steering Committee with input from our community and international partners, adhering to the following guiding principles: (1) Geared to students who are oriented to both academic and applied employment opportunities (e.g., California Office of Binational Border Health, United Nations High Commissioner for Refugees, Pan American Health Organization, clinical positions like director of a migrant health clinic); (2) Courses and mentoring plan tailored according to their career stage and prior level of experience; (3) Required and optional courses available on-site and/or at other Center campuses through distance-education; (4) Requirement of a field placement offering hands-on learning experiences related to migrant health issues; (5) Integration of community partners and their organizations/agencies as active members of the mentoring team. The curriculum content will initially draw from existing courses (e.g., the ten UC campuses offer more than 1,000 Mexico-related courses in numerous disciplines), as well as newly developed course content pertaining to global migration and its intersection with health, for example, Occupational Health. Students will be strongly encouraged to develop competence in a foreign language in order to facilitate cross-cultural research, training, and programmatic activities.

A unique aspect of our curriculum will be the availability of a wide variety of field placements in migrant communities of origin and destination that will provide hands-on training experiences for all students participating in the COEMH. Examples of placements include the Mexican Migration Field Research and Training Program based at UCSD, which annually conducts in-depth studies of health care-seeking behavior and outcomes in migrant-sending and receiving communities; a research site located in Tijuana’s red light district focusing on prevention of HIV, STIs, TB and substance use; migrant camps in rural and peri-urban areas; migrant hometown associations; nongovernmental organizations that provide services to immigrant and refugee communities, such as California Rural Legal Assistance; community health centers and refugee clinics; and public agencies such as California’s Office of Binational Border Health, the Institute of Mexicans Abroad (a division of the Mexican Ministry of Foreign Relations), Mexican consulates, and health programs for migrants operated by health ministries in high-emigration states such as Zacatecas and Oaxaca.

As a first step towards curriculum development, our Steering Committee reviewed existing postgraduate programs that address migration and health. Our search identified Master’s degree programs on ‘Forced Migration’ (University of Oxford, Columbia University), ‘Migration, Mental Health and Social Care’ (University of Kent), and Master’s programs that addressed health issues more tangentially (e.g., ‘Migration and Intercultural Relations’; University of Stavanger). However, we could not identify a single program that simultaneously addressed health issues across the broad range of migrant experiences that may impact communities of origin, transit, and those of destination. The intersection between migration and health needs to be examined in this dynamic context and within the disciplines of health, law, and human rights. Our curriculum will fill this critical gap.

All students will delve deeper into these topics by participating in a six-month Migration and Health course that will incorporate lectures by faculty at multiple campuses (shared via the Internet and video-conferencing), break-out sessions with an assigned faculty member, as well as case study and applied learning opportunities. Depending upon their career goals (e.g. leadership in government, international and domestic NGOs, advocacy organizations, academic careers), students will select from a roster of short- and longer term projects that we will identify in collaboration with our domestic and global partners, so that students can participate in on-site and long-distance opportunities. For example, while developing skills in conducting needs and assets assessments, they will work as part of a team comprised of a UC faculty member and a global partner. These mentored learning experiences will ensure that students will develop practical skills and will enable them to share their projects with other students and multinational faculty, thus receiving valuable input and opportunities for comparative study.

We recognize that there may be multiple pathways to attaining core competencies, depending on the background and education of each student. For example, a student who is interested in pursuing an academic career and is interested in refugee health may complete their field practicum with a team of researchers comparing risk factors for latent TB by country of origin among patients seeking care at a refugee clinic. Their product might take the form of a manuscript submitted for peer-review that forms the basis of a Master’s thesis. A student whose interests are more applied, who is interested in barriers to health care among migrant farm workers, may complete their field practicum by being placed with the director of a community agency. Their product could take the form of a policy brief or technical report that can assist with advocacy efforts or development of programmatic grants. Both models would benefit from skills in how to translate research into action—whether it be creating new policies that shape development and funding of new interventions in government, changing practices at the community level where culturally-appropriate, evidence-based interventions are needed, and helping international development organizations reconsider how to establish their country-level priorities in resource-constrained settings.

DISSEMINATION

The COEMH will systematically engage in broad dissemination of its research findings and their policy implications. For example, research can be used to better inform diverse media platforms to help draw attention to a specific health issue and recommendations for changes. In turn, this information can be used by a variety of advocacy efforts, as well as in developing the next generation of programmatic interventions. Dissemination will be accomplished through traditional academic venues (journals, professional meetings), by active use of traditional mass media (e.g. media advisories, briefings for journalists, placing op-eds in print media,), community-oriented communications (e.g. fact sheets, newsletters, promotoras, health fairs), and by using new media (e.g., blogs, networking tools). The COEMH will also make full use of the Binational Health Week, the largest citizen mobilization in the world for dissemination of health information to migrant communities. Students participating in COEMH programs will receive specific training to prepare them to participate in dissemination activities, and there will be structured opportunities for all students to present their work in diverse public venues.

GOVERNANCE

The COEMH encompasses all ten UC campuses. The COEMH will have shared governance, split between lead campuses in Northern and Southern California, located at UC Davis and UC San Diego, respectively. Each of the lead campuses will work collaboratively with sister institutions in their respective halves of the state: UC Davis working with UCSF, UC Berkeley, UC Merced, and UC Santa Cruz; UCSD collaborating with UC Irvine, UCLA, UC Riverside, and UC Santa Barbara. The northern and southern hubs of the COEMH will each be governed by a Director from the lead institution and a co-director who rotates between the partner UC campuses every two years. Resources will be equally split between the northern and southern components of this COEMH. The directors of the northern and southern lead campuses will be responsible for allocation of resources, in consultation with a Steering Committee that will provide oversight and operating direction. It will be composed of the two directors, co-directors from the lead campuses, and lead faculty members representing all other campuses, plus additional faculty as mutually agreed upon by the committee and established bylaws (e.g. one rotating position from an international collaborating institution, representatives from other UC campuses). The steering committee will meet at least quarterly. An external advisory board will be composed of distinguished leaders in academia, government or other organizations (e.g. foundations, NGOs) in California, Mexico, Canada, and other countries as appropriate. The external advisory board will meet at least annually and will provide leadership and oversight to the COEMH.

PARTNERSHIPS

The COEMH will develop strong reciprocal partnerships at a national and international level with key stake-holders from academia, government (local, state, and federal), the private sector, community organizations, and non-governmental agencies. The partnerships will be trans-disciplinary, involving health science and non-health science faculty and programs. These alliances will be critical in enlarging the existing UC pool of experts on migration and health, and providing important non-academic and non-U.S. perspectives. Furthermore, these partnerships will result in strategic alliances with other programs and institutions to better understand the opportunities and resolve the challenges related to health and human mobility in the 21st century. These partnerships will be long term, with defined purposes to promote and assist research, training, provision of services, and development of public policy initiatives. Memorandums of understanding or other formal agreements will describe the “nucleus” of future steps and directions.

The faculty members listed in Part II of this proposal will constitute the core group of COEMH researchers. However, faculty and graduate students with an interest in migration and health issues based at all UC campuses will be invited to participate in the COEMH’s research, training, and dissemination activities. A multi-campus web-based inventory containing relevant information will be created. Faculty will be able to identify potential partners and institutions, and to leverage resources. Partnerships with other research and training institutions as well as foundations operating in California will be critical to ensuring that the work of the SGH and particularly of this COEMH remains relevant to the government, institutions and population of the state.

Due to the international nature of this COEMH, we anticipate strategic alliances with various countries affected by migration. Major UC systemwide initiatives are already underway in four countries: China, India, Canada, and Mexico. The COEMH will leverage and build upon collaborations with these existing initiatives. UC is a natural partner for research and scholarly exchange with Mexico because of its geographic proximity, Mexico’s contribution to California population growth, UC’s infrastructure and intellectual resources committed to binational issues and a UC presence in Mexico (Casa California). In creating partnerships for the COEMH, special consideration will be given to planning of joint activities that serve each institution’s strategic goals. Exchange programs, including cultural and linguistic immersion opportunities for faculty and students, will allow participants from each institution to strengthen and further the achievements of the other and to reciprocate in the research and teaching missions.

SUMMARY

Migration is a global phenomenon involving hundreds of millions of people, with major social and economic impacts on countries of origin and destination at many levels of development. Among U.S. states, California is by far the most pervasively affected by these population movements. The COEMH will be the first multidisciplinary, university-based program in the world devoted to systematically studying the health consequences of international population movements and developing more effective strategies to address them. Such a program will serve the needs of migrants and refugees in California and around the world. The COEMH will provide leadership on migrant health issues to governments, academic programs, and stakeholders, including health care agencies. The COEMH will train a new generation of students with competencies to address migration and health issues in the 21st century. The systematic utilization of field-based learning assures that students will gain real-world knowledge of the issues impacting the health of migrants and refugees. Students will also acquire the tools needed to translate their knowledge into improved health outcomes in these populations. By drawing on the critical mass of migration and health researchers across all disciplines and from all UC campuses, the COEMH will harness an unprecedented assemblage of expertise to develop realistic interventions and policies for reducing the health disparities affecting migrant and refugee communities.

INITIAL COLLABORATING CORE FACULTY

UC Berkeley

• Maria Blanco, School of Law
• Xochitl Castañeda, Health Initiative of the Americas/School of Public Health
• Sylvia Guendelman, Community Health & Human Development
• Beatriz Manz, Geography and Ethnic Studies
• Nancy Scheper-Hughes, Anthropology

UC Davis

• Adela de la Torre, Chicana/o Studies
• Kevin Johnson, School of Law
• Sergio Aguilar-Gaxiola, Internal Medicine
• Luis Eduardo Guarnizo, Human and Community Development
• Marc Schenker, Public Health Sciences

UC Irvine

• Frank D. Bean, Social Sciences/Center for Research on Immigration, Population and Public Policy
• Leo Chávez, Social Sciences
• Greg Duncan, Education
• Andrew Noymer, Public Health
• Rubén Rumbaut, Social Sciences

UC Los Angeles

• Gail Harrison, Public Health
• Marjorie Kagawa-Singer, Public Health
• Michael Rodríguez, Family Medicine
• William Vega, School of Medicine
• Steven Wallace, Public Health

UC Merced

• [to be added]

UC Riverside

• Kevin Esterling, Political Science
• Augustine Kposowa, Sociology
• Juliet McMullin, Anthropology
• Karthick Ramakrishnan, Political Science

UC San Diego

• Kimberly Brouwer, Department of Medicine
• Wayne Cornelius, Political Science/Center for Comparative Immigration Studies
• David FitzGerald, Sociology/Center for Comparative Immigration Studies
• Victoria Ojeda, Department of Medicine
• Steffanie Strathdee, International Health/Department of Medicine

UC San Francisco

• Claire Brindis, Pediatrics/Philip R. Lee Institute for Health Policy Studies
• Estéban Burchard, Genetics
• Margaret Handley, Family and Community Medicine
• Eliseo Perez-Stable, Department of Medicine
• Leslie Wilson, Economics/School of Pharmacy

UC Santa Barbara

• David Carr, Geography

UC Santa Cruz

• Jonathan Fox, Latin American and Latino Studies
• Shannon Gleeson, Latin American & Latino Studies
• Patricia Zavella, Latin American & Latino Studies