Issues in Relation to Health and Place Concerns Migration
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Anne McMurrayandJill ClendonCommunity Health and Wellness, Chapter 2, 24-41Open reading modeClose reading modeThere was an error loading this content. Please refresh the page to try again, or contact us ifyou continue to experience problems.IntroductionThe notion of reciprocal determinism, whereby people affect and are affected by theirenvironments, epitomises the relationship between health and place. Place is important torelative states of health because ‘itconstitutesas well ascontainssocial relations’ ( Cumminset al. 2007 :1825). Having a geographically bounded ‘community of place’ where peopleinteract with others can help promote community attachment, cohesion and solidarity( Kilpatrick et al. 2009 :285). As we know, certain places are more conducive to health andwellbeing because of their physical features. But places also affect the social and emotionalaspects of health and wellbeing. People feel grounded in certain places, but these need not beonly defined by a particular geographic boundary or distance or proximity to others.Interacting across multiple places has interesting effects on people's behaviour, particularly interms of power relationships that allow some people to negotiate access to services and otherresources, while constraining others' ability to have equal access. Resources and supportsystems may also be more readily accessible to those with differing socio-demographic andcultural factors, such as age, gender, employment status, ethnicities and religious beliefs( Cummins et al. 2007 ). These factors are all integral aspects of the SDH. So in terms of‘place’ the effect of older persons being at home rather than in the workplace may create adifferential health disadvantage or advantage, just as the neighbourhood may have differentialeffects on an adult or a young child, depending on the extent to which they are able to spendtime in parks or other recreational facilities. In today's world, where there is an increasingconcern about our global and local places, there is a need to look more closely at theintersection of health, place, and our personal geographies and how we transit throughmultiple contexts in the pathways to good health.One of the most important issues in relation to health and place concerns migration andcultural viability. Just as land and water shortages have caused forced migration, wars,urbanisation and poverty have driven people all over the world to assimilate into foreigncultures. As a result, the world has lost languages and culturally diverse elements that havehistorically maintained cohesion and trust. In some cases, the fear of protecting borders fromrefugees and other migrants has had the effect of disempowering some cultures. This in itselfis a health hazard, as the disappearance of cultures and traditional ways of life have left
whole communities without an understandable means of sustaining health or avenues forcommunicating with others. Their cultural disempowerment is therefore an important factorin determining the extent to which they flourish in family and community life.The challenge in all communities is to find local, sustainable solutions and a sense of controlorcommunity comfort.As health professionals we assume an advocacy role, helpingcommunities construct pathways to change on different levels. As social advocates, we adopta respectful and culturally sensitive approach, shifting the balance of power to thecommunity. As political advocates, we bring knowledge about the health and welfare systemsto the table and help link people together to access resources. As professional advocates, wehave an obligation to stay abreast of new knowledge and strategies that will help us maintainprofessional competence as well as solidarity with others. These processes are developmentalin that by working together, people's skills, knowledge and self-confidence are developed,ultimately empowering them to go on to the next undertaking. Facilitating and enablingcommunity empowerment also helps develop the skills of the health professional. Eachcommunity and the strategies it uses to strengthen capacity are unique, so every opportunityto work with a community yields new information that the health professional can use toconsolidate and refine health promotion skills. In this respect, advocacy is a deliberate two-way process of mutual development, beginning with the global community.What's Your Opinion?Health professionals act as social, political and professional advocates.In what ways have you seen these differing dimensions demonstrated in your community?ObjectivesBy the end of this chapter you will be able to:1explain the relationship between health and place2outline the global factors that influence community health and wellness3identify the major aspects of urban life that affect the community4analyse the pros and cons of rural lifestyles in relation to social capital5explain the effects of FIFO lifestyles in terms of the social determinants of health
6explain how the health of young people is enhanced by the ‘layers’ of assets availableto them in their social media communities7develop a planned approach to creating a ‘Healthy City’ that will help ease thetransitions for migrants and refugees.The Global CommunityAs part of the global community we need to be mindful that what occurs in one countryaffects all others. As mentioned earlier in the chapter, we depend on our natural ecosystemsto provide life support throughout the world, and this affects our health and that of ourcommunities ( Hancock 2011 ). The global community has a profound impact on our socialworld, particularly in terms of economic capabilities and our ability to access the social andcultural supports that help conserve our communities. Globalisation is therefore relevant tofamily life across the age continuum and across generations, from birth and child care toeducation, employment, recreation and a comfortable retirement. Our globalised world hasbrought significant changes to community life, some more dramatic and far-reaching thanothers. Global technology has enhanced knowledge for many people, providing instantelectronic access to a wealth of information, including health information and research data;however, it has also created inequities.The term ‘globalisation’ refers to integration of the world economy through the movement ofgoods and services, capital, technology and labour ( Labonte & Schrecker 2007a ).Integration of these economic capabilities means that economic decisions affecting people inall corners of the world are influenced by global conditions. When we first encountered thenotion of globalisation in the 1980s it seemed a palatable idea. A globalised world held thepromise of increased markets for goods, porous borders through which people could passfreely, greater sharing of cultures, and economies of scale where goods might becomecheaper because they could be bought and sold efficiently by large business concerns.Economic arrangements since globalisation have added wealth to various nations, reducingabsolute poverty(the total number of people living in poverty). However, inequities havebecome evident from the fact that global markets privilege the global elite, those in control oftrade relationships, who have profited enormously from worldwide commercial endeavours atthe expense of social, environmental and health concerns.GlobalisationIntegration of the world economy through the movement of goods and services, capital,technology and labour.Open full size imageThe political environment that paved the way for globalisation was one that valued not onlyfree trade between nations, but deregulation of financial markets and a host of other financialdecisions that ultimately created the 2008–09 global financial crisis. The crisis occurred
primarily because too much power was vested in a small number of multinational globalorganisations, dominated by the wealthiest countries in the world, whose leaders madedecisions that allowed them to control the lion's share of the global economy and world trade.With global markets gaining control over products and services industrialised economieshave flourished, but many countries and communities have become impoverished in theprocess, especially those who were already poor. In some cases, multinational companieshave destroyed the livelihood of entire farming communities by importing cheaper goods,effectively reducing the incomes of workers producing domestic products ( Cushon et al.2010 ; Labonte & Schrecker 2007a b ). Large investors now control agricultural productsthroughout the world, which has created a food crisis in a number of developing countries( Schrecker 2011 ). Because of competition and an inability to find markets for their food,some developing countries have stopped growing crops, leading to a vicious circle of poornutrition, foregone education and ongoing illness among the most disadvantaged in society( Navarro 2009 ). Other sources of production have become non-viable, as the products arenow constructed in countries where both labour and taxes are cheap. This system maximisesprofits for the global company but erodes the local economy and its tax base that could havebeen used to fund infrastructure and support systems for health ( Schrecker 2011 ). Workersin these countries who are engaged in the new production processes are also exposed to newworkplace hazards and industrial pollution, which have been tolerated to increase labourmarket position. Some have become deskilled, once again, magnifying inequalities betweenrich and poor countries.Large financial institutions have also played a part in eroding the local economy of small,developing countries. Over the last twenty years the International Monetary Fund and theWorld Bank provided loans to those nations that agreed to adopt ‘structural adjustmentpolicies’ to reorganise their economies, but this placed them in a precarious, disempoweredposition. Because the loans were also provided indiscriminately to political leaders who hadno moral obligation to defend the legitimacy of their rule, many local communities weredeprived of democratic participation in decision-making. This type of non-inclusive,autocratic decision-making allowed a number of despotic rulers to maintain their leadershipthrough repression ( Labonte & Schrecker 2007b ). To make matters worse, foreign loanrepayments have been shifted to safer, tax-free havens, which stripped many developingcountries producing goods of tax funding that may have been used to improve citizens'quality of life ( Schrecker 2011 ).Group ExerciseGlobalisation and nursingIn groups of two or three, consider how globalisation may affect your practice. Consider theimplications of commodification on job opportunities for new graduates, the drive forefficiencies and costs savings within health services, and the impact of globalisation on thepeople you care for.Add to your answers as you work through the chapter and report back your findings to thewider group. If working online, start a discussion forum on each of the above questions.Some African and Asian countries have experienced this type of inequity for many years.People in Zimbabwe starve to death regularly. In Bangladesh, which is the poorest country inthe world, only a fraction of the food aid reaches the poor, the majority of it being given to
the government, which sells it at subsidised prices to the military, the police, and middle-class families ( Navarro 2009 ). Such inequality is not confined to developing countries, asthere has been a parallel situation in many Western nations, where indiscriminate lendersallowed people and institutions to borrow money from them without them having the meansor job security to repay their loans. This type of practice has led many families to the brink ofpoverty, to ‘survival circuits’ of low wage jobs and a cycle of debt from which they cannotrecover ( Schrecker 2011 :205).Because globalisation has changed the focus of institutions from providing locallyappropriate services to economically efficient services, health, education, transportation andother services have becomecommodified.What this means for health care is that if aparticular service is seen as inefficient, it is typically downsized or removed, and people whomay have relied on the service have to travel to a central location, creating a burden onpeople in many communities, particularly those at a distance from specialist services.Investors' search for cost effectiveness has also resulted in the casualisation of the workforce.Where a service is dominated by cost rather than continuity, job security and benefits areoften eliminated ( Cushon et al. 2010 ). A further layer of disadvantage has arisen throughprivatisation of previously public services, which has led to user fees for health care andeducation. In addition, multinational pharmaceutical companies now dominate the trade inmedicines, creating higher costs with no accountability to current and future generations inrelation to local development or any social or environmental damage they may cause ( Baum2009 ; Labonte 2008 ; Schrecker 2011 ). The growing number of free trade agreements (forexample, the Trans-Pacific Partnership Agreement (TPPA) negotiated between the UnitedStates, Canada, Mexico, Peru, Chile, Vietnam, Singapore, Malaysia, Brunei, Japan, Australiaand New Zealand, and the Regional Comprehensive Economic partnership (RCEP) betweenthe 10 ASEAN states, together with Australia, China, India, Japan, Korea and New Zealand)further exacerbates these issues, placing the interests of global companies well above theinterests of local communities (seeBox 2.1).Box 2.1The Trans-Pacific Partnership AgreementThe Trans-Pacific Partnership Agreement (TPPA) is a trade agreement under negotiationbetween Australia, New Zealand, the United States, Canada, Mexico, Japan, Peru, Chile,Vietnam, Singapore, Malaysia and Brunei. However, the TPPA is much more than just atrade agreement. Instead of being simply about freeing up trade in goods and servicesbetween countries, the main focus of the TPPA is to create an attractive environment foroverseas companies who want to operate in Australia and New Zealand. What this means isAustralian and New Zealand laws on environmental protection, public health, intellectualproperty and economic regulation will be restricted to make it easier for foreign companieswho wish to invest in Australia and New Zealand. In particular, US-based pharmaceuticalcompanies are lobbying for provisions that will reduce government regulatory control ofpharmaceuticals threatening equitable access to medicines (Faunce & Townsend 2011). TheTPPA would also give foreign investors the power to sue the New Zealand or Australiangovernments in secret tribunals if they think that changes in law or policy have caused asubstantial financial loss to their New Zealand or Australian investments. For example,tobacco companies would be able to sue governments if plain packaging has a detrimentaleffect on profits.
One of the most concerning aspects of the TPPA is that it is being negotiated in secret andthere is no opportunity for community members to have their say in whether the TPPA goesahead. And if it does go ahead, it will bind Australians and New Zealanders to a set of rulesdesigned in the interests of big business, not everyday people. More information on the TPPAin New Zealand can be found at:www.itsourfuture.org.nzand in Australia at:http://aftinet.org.au/cms/.How is this related to community health?Commitment to communities requires vigilance and advocacy so that people are aware of thelayers of decision-making that affect their lives. In the context of PHC and the goal of socialjustice it is important to question whether policy decisions are made with equity in mind.There is widespread concern about our global community among those attempting to promotethe health of local communities. These concerns all converge on the centralisation ofdecision-making and the effects of these decisions on health. Researchers cite the healtheffects of excluding some nations from the global market, particularly the developingcountries, many of which are already suffering from communicable diseases such asHIV/AIDS, tuberculosis, hepatitis and malaria ( Schrecker 2011 ). These diseases, and theinequities of globalisation have affected women disproportionately, many of whom werealready disadvantaged by poverty and discrimination and who, in a competitive globaleconomy, have no hope of improving their situation ( Falk-Rafael 2006 ; Schrecker 2011 ). Insome developing countries the mass migration of health professionals has also eroded thecapacity of the remaining workforce to deal with the burden of illness or health promotion.While many Western nations are happy to welcome migrant health professionals to fillworkforce shortages, the net loss of these health workers has caused the near collapse ofalready fragile health systems in their home countries.What's Your Opinion?Globalisation has had a significant impact on individuals, families, communities and nations.What negative and what positive impact has globalisation had on you as an individual, yourfamily and your community?The politics of global health care is clearly an issue for all nations. The global financial crisisof 2008–9 impoverished many people, sweeping the world with new claims on public moniesand alarming discussions about resource scarcity. Decisions taken by global leaders led to areduction in funding for HIV/AIDS, tuberculosis and malaria programs to the extent that in2010 annual funding for these programs was cut in half to US$9.2 billion ( Schrecker 2011 ).Yet US$1 trillion is spent globally each year on arms and armaments ( Schrecker 2011 ).Surely there is an ethical and moral argument to be made for decentralised decision-makingthat would allow each community to establish its own priorities based on local needs. In fact,in recognising the need to decentralise their local economies, some developing countries haveseen the development of micro-financing at the neighbourhood level, aimed especially athelping impoverished women start their own businesses. This approach has provided smallloans, savings, insurance and training to people living in poverty as a just and sustainablesolution to alleviate global poverty (10thousandgirl, Online. Available:www.10thousandgirl.com/some-facts/how-microfinance-works/[accessed 21 December2013]). Although modest, some of these businesses have helped break the intergenerational
poverty chain, helping women become empowered through viable employment that alsohelps ensure an education for their children. Micro-financing developments are one of thepositive outcomes of globalisation, for without global attention and support, poor countrieslike India and some African countries would not have had these opportunities.Despite the global attention to poverty in developing countries, another effect of globalisationhas been the loss of cultural identities, languages and the right to choice in securing the bestlevel of health for the most number of people. The reality is that even as countries of theWest celebrate new wealth, we are all aware that wealth is distributed unequally. So as theglobal community has continued to develop, there have been greater disparities between richand poor countries, and between the rich and poor within most countries. Clearly,globalisation has wreaked havoc with the SDH. As Navarro (2009 :440) declares, ‘it is notinequalitiesthat kill, but those who benefit from the inequalities that kill’. This includes thedecision-makers who engage in a form of ‘predatory capitalism’ ( Schrecker 2011 :205) tocontrol food and tobacco, pharmaceuticals, financial markets and health care ( Dickens 2011 ;Schrecker 2011 ). The effects of their decisions cascade throughout society, affecting thepoor and vulnerable, including women workers, migrants, different cultural groups, and ruraland urban dwellers.Urban CommunitiesFor the first time in history half of the world's population (3.4 billion people) live in cities( WHO 2011 ). Many of these city dwellers are at the lower end of the social gradient andtherefore subject to inequitable living conditions, but even middle-class urban residents canbe affected by inequities in relation to those who are better off because they enjoy fullemployment ( CMAJ 2011 ). Across the global spectrum, many cities have experiencedexplosive growth over the past two decades, either through personal choice, migration to findemployment or to escape wars and civil strife or environmental degradation ( Satterthwaite &Mitlin 2011 ; WHO 2011 ). In most parts of the world, the major cities are bulging at theseams, trying to accommodate the vast influx of new residents. With growth in numbers therehas been a growth in urban poverty, and research has shown that cities contain the largestproportion of those who are malnourished, have poor living conditions, and high maternaland infant mortality ( Satterthwaite & Mitlin 2011 ; WHO 2011 ). On the other hand, the costof providing clean water, sanitation, schools, education and health care is more affordable inurban areas because cities enjoy better infrastructure than rural areas ( Satterthwaite & Mitlin2011 ).In the city, the layered dimensions of life are played out in daily exchanges of social life andcommerce, in celebrations and exploitative acts, through illness and wellness, and across thelifespan from birth to death. Urban life is a microcosm of the many relationships betweenhealth, social, cultural and environmental factors, portraying both visible and hidden aspectsof family and community life. As population density increases in the cities, the differentialeffects on health and wellbeing for the rich and poor come into clear focus. For theunemployed or disadvantaged by birth or illness, the risks and hazards of city living includecrowding, violence, virus infections, motor vehicle accidents, exposure to harmfulsubcultures such as substance abusers, environmental pollution and social exclusion ( WHO2011 ). Yet there is a close connection between what is occurring in rural communities and inthe cities. In some cases, the hopelessness seen in impoverished city dwellers reflects thephysical and social degradation of rural areas, which has brought many people to the citywithout their previous support systems.
Up Side, Down Side to the City•More services, more jobs, more people•Higher costs, poverty•Inequities•Substandard housing, crowding•Fewer family supports•Crime, pollutionLife in the city is increasingly inequitable. As the rich get richer, the divide between the‘haves’ and the ‘have nots’ becomes more entrenched, and this erodes social capital( Hancock 2009 ; Kawachi & Kennedy 1999 ). For the ‘have nots’ life holds fewexpectations, given the drift of wealthier citizens out of the city and into the suburbs, leavingbehind an inflated housing market that is out of reach of many of the working poor. Thewealthy also take with them the tax base that might have funded additional services in thecore of many cities. Because of declining commerce and conditions in the heart of the citymany economically disadvantaged people are relegated to lower paying jobs. At the sametime, most urban societies have an unprecedented need to support older citizens and otherfamily members, especially for migrant and refugee families. Many live their lives insubstandard housing, which places all family members, particularly children, at risk of illhealth. Homelessness, the ultimate marker of disadvantage and inequality in society, is aparticular concern, as inadequate shelters struggle to keep up with demand for food, clothingor safety. Many homeless people are the mentally ill who have been left on the streets bydeinstitutionalisation and the inadequacy of mental health support services ( WHO 2011 ).Among the homeless is a growing number of adolescents and young families whose wageshave not kept up with housing costs, a situation that has been worsened by the globalfinancial crisis. One short-term solution has been house sharing, which has becomeincreasingly common among low-income New Zealand families trying to cope with limitedbudgets and rising costs. However, this solution has resulted in severe overcrowding, whichexacerbates the risk of infectious diseases such as rheumatic fever and respiratory infections—both diseases with marked prevalence in New Zealand ( Sharpe 2012 ; Trenholme et al.2012 ).