Podcast: Child health outcomes of parent and child migration, a global health perspective

Delan Devakumar

Delan Devakumar is a professor of global child health and honorary consultant in public health. He was on the steering group and a Commissioner of the UCL-Lancet Migration and Health Commission (The Lancet 2018). His work mostly focuses on how racism and xenophobia affect the health of children and adolescents.

Akanksha Marphatia

Akanksha Marphatia is a Research Fellow at the London School of Hygiene and Tropical Medicine and Honorary Staff at UCL Great Ormond Street Institute of Child Health.  Her research examines the life course emergence of educational and economic inequalities, and the impact of early women’s marriage (<18 years) on a range of bio-social outcomes related to women and their children in Nepal and India. Akanksha has a PhD in Human Geography and an MPhil in International Education from the University of Cambridge and holds an EdM in International and Comparative Education from Harvard University’s Graduate School of Education. Prior to her PhD, she worked in international gender and education policy across Sub-Saharan Africa and South Asia.

Laura Busert Sebela

Laura Busert-Sebela is a research consultant working in the fields of migration and maternal and child nutrition in low- and middle-income countries. She has recently received a PhD from UCL Great Ormond Street Institute of Child Health. Laura’s research interests focus on the determinants of child growth in low-income settings, especially Nepal. Her recent research investigated the association between paternal migration and the growth of the children left behind in the home communities in the plains of Nepal.

Alice Armitage

Alice is a paediatric consultant with an interest in complex safeguarding and vulnerable populations. She is currently completing a doctorate at UCL on migrant child health supervised by Prof Michelle Heys. Alice has held academic positions throughout her training with research interests including female genital mutilation, sexual assault in adolescents and migrant health. She has also worked in low-resource settings including the Gambia, East Africa and in refugee camps in Greece and Bangladesh. She is currently named on two grants developing services for unaccompanied asylum-seeking children.

Susanna Corona: a medical doctor and global health researcher with an interest in migrant children and adolescents. She conducted her PhD on the impact of migration transit on mental health of unaccompanied migrant youth in Mexico.

Emeline Rougeaux: a global health researcher with an interest in urban environments and inequalities. Her research has explored child health inequalities in the UK, maternal internal migration and child nutritional health and growth in Peru, and stress and non-communicable disease in adults in Accra, Ghana.

Abubakar I, Aldridge RW, Devakumar D, Orcutt M, Burns R, Barreto ML, et al. The UCL-Lancet Commission on Migration and Health: the health of a world on the move. The Lancet. 2018;392(10164):2606-54. doi: https://doi.org/10.1016/S0140-6736(18)32114-7

Fellmeth G, Rose-Clarke K, Zhao C, Busert LK, Zheng Y, Massazza A, et al. Health impacts of parental migration on left-behind children and adolescents: a systematic review and meta-analysis. The Lancet. 2018;392(10164):2567-82. doi: https://doi.org/10.1016/S0140-6736(18)32558-3

Corona-Maioli, S, Stevens, A., Pinto, A. C., Linthout, L., & Devakumar, D. (2023). Improving safeguarding of unaccompanied migrant young people. BMJ, 383. doi: https://pubmed.ncbi.nlm.nih.gov/37967887/

Lancet Commission on racism and child health (online link) 

The International Data Alliance for Children on the Move (online link)

Susanna: Migration is often a hot, political topic. However, mainstream media and discourse almost never go into the details of the complexity of this issue. I am Susanna Corona. 

Emeline: And I am Emeline Rougeaux.

Emeline: We are two migration academics from UCL and, in this podcast, we are going to explore some of the nuances of migration specifically for women and children, including the impact of migration on their health. We are going to take you on a journey with four different researchers who study this topic from different points of view.

Susanna: First, we interviewed Delan Devakumar, professor of global child health in UCL, and we asked him to give us an overview of what is migration. 

Delan: The usual simplest form of definition is just moving to live somewhere else. What we mostly think of as migration is moving across from one country to another, the international migration. Actually, migration within a country is probably much more common and a lot more people do that. Migration has always happened and it happens everywhere around the world, so it's a normal part of human life and going back in time, everyone migrated, humans started in Africa, moved across Africa and then out of Africa and across the world

Susanna: And what kind of numbers are we talking about, how many people move? 

Delan: So there are a lot of migrants around the world. I think it's important to start there, that internationally, there are 281 million migrants, and that is 3.6% of the world's population. If we include internal migrants, there's probably about three times as many internal migrants. We're talking about a billion people overall who are classified as migrants. But the internal migrant number is not… it isn't known very well.

At the moment there's 108 million forced migrants in the world. And this number has increased fairly dramatically over the last decade (…) from around 2011 that number has gone up from 40 million to 108 million which is where we're at now. Of those migrants, 35 million are refugees. There are 5 million asylum seekers. But the biggest number is actually people displaced within a country, which is 63 million internally displaced people. Most of these people come from a small number of countries. From Syria, Ukraine, Afghanistan, for example  (…) and the overall picture of migration in terms of the 281 million migrants I mentioned before that that's gone up a little, but as a proportion of the world's population it hasn't changed massively. It's gone up from around 3% to 3.6%. But this number of forced migrants has increased, in that you can think of all the conflicts that have happened the last year or 10 years or so.

Susanna: Increasingly, we see many people who cannot stay in their countries due to conflict, poverty and climate disasters, such as drought or floods. We also asked Delan, who are the people migrating? And what kind of patterns can we find based on the ages or reason for migration?

Delan: it's usually young adults who migrate moving for work, this idea of circular migration where someone might move, spend some time in another place to work, then return home and then move again to somewhere (…) And then families often move with the people who are migrating so children will move, parents, other relatives will move.

Emeline: indeed most migrants are young adults, particularly men, though we've seen a feminization of migration across most regions, meaning that an increasing proportion of migrants are women. This has demographic impacts on both the places of origin and destination. Notably in rural areas, for example, it can mean an increase in the proportion of older adults, women and children, and that in turn may impact the labour available, in turn impacting economic productivity. This might result in increased household deprivation - though sometimes this can be alleviated by remittances from migrants. At the destination, while the influx of young migrants may have benefits, it also contributes to population growth, increasing competition for jobs and putting a strain on services and housing, particularly in lower income countries. Though most migrants are adults it is important to consider that children, or the population under 18 years old, are also a considerable proportion. In China roughly 5% of children (14.3 million) had migrated with their parents in 2019. The Indian census from 2011 indicated that one in five internal migrants was a child and half of these had migrated alone.  

Susanna: In fact, the most recent estimate of global unaccompanied migrant children globally is actually pretty old, summing at 300,000 in some 80 countries in 2015-16,  7 years ago, likely an underestimate and much higher today. To understand more about child migration, we interviewed paediatric doctor Alice Armitage from the UK, who studies migrant child health, and we asked her the general proportions of children and young people within migrants:

Alice: So of that 280 million a relatively small percentage, probably around 13% are children and young people, and that 280 million reflects economic migrants and international students as well as the more vulnerable groups. But if you only take the group of forced migrants, so refugees, asylum seekers, undocumented migrants, who are much more vulnerable, between 40 and 50% of them are children under the age of 18. And I think that fact is very poorly understood and frequently missed in discourse around migration (…) I think internationally, there is a recognition that we are lacking data on migrant children. And there's something called the International Data Alliance for Children on the Move that was launched in March 2020 by a group including UNICEF and the UNHCR. And so the aim is that we will in future have more comprehensive statistics and data on migrant children

Susanna: Alice also talked to us about the unaccompanied group, who are mostly adolescents who travel on their own to either become the family provider, rejoin family members, or escape from family or other violence, conflict and poverty. As we mentioned earlier, for  this specific group, in legal terms called unaccompanied minors, there is very little data:

Alice: what is lacking is any kind of linked up data between countries or any kind of longitudinal data. Even in the UK, for example, although we collect good data on unaccompanied asylum seeking children, once they leave children’s services things become much more unclear and we are not really consistently following up the data on these young people.

Susanna: So what are some of the challenges on collecting numbers of unaccompanied children? 

Alice: these young people, particularly those who are unaccompanied asylum seeking children often face prejudice in multiple forms, but including having their age contested and claims that they are not under the age of 18. And some of the problems come from our assumptions that systems all over the world are similar to our own. So, for example, across Sub Saharan Africa, only about 50% of births are registered. And the cultural concept of a date of birth having a birthday might not be recognised in a lot of countries. And yet we assume that if a person doesn't have a date of birth, that they are entirely consistent on that that is a cause for suspicion.

Susanna: Indeed, children that are most vulnerable are those who already are in disadvantaged situations from their country of origin, something that migration reception systems should take account of - but they generally do not.

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Emeline: As touched on previously there are many drivers of migration. Most often these are socio-economic. Poverty, lack of employment, high socio-economic inequalities will push people to seek work elsewhere within their own countries or abroad. In some cases it is a single household member moving to work or to send money back to the household. While some research has suggested that financial remittances may alleviate rural poverty, this fails to consider the high costs incurred by migration, particularly abroad, or the impacts on individual women and children who are left behind. We discussed this with Dr Laura Busert Sebela. In 2018 Laura followed up a cohort study of Nepalese children born in 2012 in order to assess how being left-behind by fathers migrating for labour might have impacted their growth. First tell us Laura, how common is father's migration in Nepal? 

Laura: Migration is extremely common in Nepal,in 2019, a nationally representative survey found that one in five children had a father working abroad at the time of the interview, and we could say is similar to data in our own cohort of six year old children. What we found there was that two out of three fathers had worked overseas at some point in the children's life.

Emeline: These findings support those from a large systematic review you also collaborated on alongside Delan which found that 30-40% of rural children across many countries such as China, Ecuador, and South Africa had been left behind by one or both migrating parents. This review concluded that "parental migration is detrimental to the health of left-behind children and adolescents, with no evidence of any benefit". What kind of impacts of father's migration did you find in your research in Nepal Laura?

Laura: The first factor that I want to mention or the first way that was left behind families are affected is probably quite universal, which is the disruptive effects of father's migration, especially shortly after the migrants departure when the family needs to adapt to the new situation and the absence of the family member. And initially, the financial situation of the family can also be quite difficult because it does take some months before the migrant can send remittances for the first time. And another factor that I want to mention that touches upon what I just said is the financial burden of going overseas.

So prospective migrants need to pay a lot of fees to be able to go overseas. And typically they cannot pay that out of pocket. So they have to take up a loan at very high interest rates. And this leaves them in a very high debt burden. Another factor, another way in which migration affects left behind families is that women are they're left without the support of the husband, which means they have a higher workload, and consequently, less time for childcare. And also, they are left without support in case of disputes. So in countries such as Nepal, where women typically join the husband's household after marriage, they often rank quite low in the family hierarchy. And they depend on the husband to speak on their behalf. And another factor that I found was when husbands leave during pregnancy, or shortly after childbirth, they leave their wife in a very vulnerable situation. Another study in the past have found that left behind women have fewer antenatal care visits, they're less likely to have adequate rest and support during pregnancy, they're more likely to experience depression, and also more likely to experience gender-based violence by their own family members, but also from other members in the community. 

Emeline: These are really important findings, especially considering how common father's migration is in some settings. With this in mind, do you think interventions to reduce labour migration might be the way forward, or interventions to better support families left behind could be more realistic or impactful?

Laura: I personally don't think interventions to reduce labour migration would help these families because as long as there is demand for labour from overseas, people will try to leave and they would even resort to illegal labour migration, which just makes them more vulnerable to exploitation. So what I think families need is alternative job opportunities in the home communities. So that it doesn't seem that labour migration is the only option for them to earn a decent salary. And what I think prospective migrants also need is to be conveyed a realistic idea of what labour migration entails, including all the risks and costs. Because after taking into account the large costs of migration, the net benefit often really isn't that high. And another thing that would need to happen to support left-behind families is to make migration safer. Organisations like Amnesty International repeatedly report instances of fraud and human rights violations against labour migrants. And as things are the migrants are largely unprotected against these because the policies that were created to protect them just aren't implemented in the home countries.

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Emeline: While labour migration is a very common form of migration, migration will often occur in relation to lifecourse transitions such as exit from education, entry into the labour force, or union formation. Despite migration for marriage being very common in some settings, particularly for women, it remains an area which has been little researched. We interviewed  Dr Akanksha Marphatia who like Laura, has been working with longitudinal studies that follow children as they develop from birth to adolescence, as well as drawing on large surveys of married women in India and Nepal.. Akanksha, first tell us how is marriage related to migration? and why does this particularly concern women?

Akanksha: In South Asia, the norm is for women to relocate to their husbands house upon marriage. Generally, we don't consider women's marriage as a form of migration. But if we think of migration, in its broadest sense, as moving geographically from one place to another, then marriage is very much about migrating. It's important to point out that while a small proportion of boys also marry early in South Asia, it's really the women who make the move into the husband's home. So they're the ones migrating boys don't have the same adjustment to make into an entirely news geosocial niche, they of course, have to adjust to the life coming to their household, but it's a different kind of adjustment. Just to emphasise really the importance of seeing women's early marriage as a form of migration, because we forget that and by forgetting that she's physically moving households and having to relocate and adjust to a whole new family. You know, that's not even thinking about the dynamics she has to establish with her new husband. It's the whole family, because in South Asia, girls tend to move in with the husband's family already that's a major, major transition. And I think we really overlook it, because we don't think of it as anything important. It's just what happens. It's the norm in a society. But it's specifically that migration that shifts in physical and social location, which is going to shape her future life course and that of her children.

Emeline: Why do you feel that it is important to better understand marital migration within public health?

Akanksha: If we think about the geo social niche of the woman's marital household, where she migrates into is really important, because that's going to shape both her life course and the life course of her children. And so the kind of household that girls tend to marry into is really important to understand. And what we're seeing in our research is the type of household they marry into, is in large part associated with their age at marriage. And what we have seen in our research is evidence for an intergenerational cycle of disadvantage, which has been perpetuated through early marriage. 

Importantly, we have found that maternal marriage age and education were actually the more relevant factors shaping the life course of their children, rather than household wealth or caste. So for example, in lowland rural Nepal, we found that women who had married as adolescents were more likely to be lower educated and have lower nutritional status, which was indexed by shorter stature. These early married women are also more likely to give birth to premature babies. And in rural India, we had a cohort that we followed both the mother and her daughters up to the age of 24. What we found there is that the girls who were born premature, were also more likely to marry early themselves. So we're also seeing that the children of the early married and less educated women themselves had lower education and poor nutritional status. And the girls of these early married women also married early and they had the children at a younger age. So for women, this form of migration through marriage, which is widely practiced, and hence the consequences are likely to be far reaching across generations. And in terms of just numbers we know in 2023, according to UNICEF, one in five women aged 20 to 24 years were married before the age of 18. This is approximately 650 million women so, the extent to which this issue could actually propagate into the next generation is quite, quite large.

Emeline: Your findings suggest there could be important health gains by reducing early marriage in settings like Nepal.

Akanksha: The payoffs for marrying later include more education for girls. And this is important in its own right. And it also may give girls more confidence and knowledge to improve both their own health and that of their children. Marrying at a slightly older age, even 17 years, may mean that girls are also able to better negotiate the dynamics in their marital household, and yes, as the household that they migrate into, they know very little about. Biologically, we know that later marriage would enable girls to develop physically and be mature and be ready for both marriage, but certainly motherhood. Marrying later also means that girls get a chance to experience adolescence and not just go through straight away from childhood or early adolescence to womanhood and motherhood through marriage. Not everybody's going to experience this migration in the same way. It's important to recognise that even girls who marry early, they may actually be marrying into a better situation and their natal households. So it's important to understand both sort of the positive and the negative sides of migrating for marriage.

Emeline: I agree, it is important to consider there may be both negative and positive impacts of migration. when we consider internal migration specifically, much of this occurs from rural to urban areas or towards areas of greater urbanization. While this may be accompanied by socio-economic improvements and better access to amenities, services and a greater diversity of food, studies have shown it is associated with increased exposures to pollution, a greater consumption of unhealthy and processed foods, and reduced physical activity.

This likely explains why in my own research on internal migration in Peru women who migrated from rural to urban areas had children with better linear growth but a higher risk of obesity in early life when compared to women who had stayed in rural areas. These associations were found in all children regardless of whether they'd migrated with their mother or were born after, though differences were largest in the latter echoing those from other settings like Tanzania. The impact of migration on health may however vary by child health outcome as well as by context and type of migration. For those who migrate within humanitarian contexts or in difficult circumstances, particularly across borders, the impacts on health may differ, as we discuss after the break.

[music break – health impacts]

Susanna: Especially when forced, migration has significant health impacts. Professor Delan Devakumar was part of an important UCL-Lancet Commission on Migration and Health launched in 2018, and we asked him to give us an overview:

Delan: I guess the focus of the Commission was to summarise the evidence initially. Migrants are usually healthy to begin with. Then the conditions that they face. It's the conditions of the travel the conditions that they find when they get to their destination, what kind of access to they have to health care when they get to the destination? What kind of places do they live in, what kinds of food do people eat, or the environmental causes of ill health and those tend to put migrants at increased risk of becoming unwell. And we see this in physical health outcomes and also mental health outcomes. And then what we did was to focus on some of the myths around migration. So there’s this idea that migrants bring infectious diseases to host population and that isn’t the case, the evidence suggests that it is actually migrants who are more likely to get unwell. And that’s really about how the health system is set up. Are there immunisations in place, are there sufficient preventative measures for infectious diseases, treatments for infectious diseases. So its more about the health system than about the migrants themselves.

Delan: There are these sensitive periods in childhood where your development is affected more strongly depending on when you move, so particularly in early age, and also in adolescence, it's a particularly important time. So if children migrating at the time, if they face adverse circumstances in that time, their impact can happen immediately and it can also last for several years after.

Susanna: Dr Alice Armitage agrees:

Alice: Among children and young people under the age of 18, as well as the challenges facing any migrant, children have inherent additional vulnerabilities. So for example, to violence and exploitation to malnutrition to infectious diseases, and part of what motivated my work is, it seems that no one's really answered the question of is there a so called Healthy migrant effect among children and young people or do their vulnerabilities massively outweigh the other effect?

Susanna: Alice conducted a systematic review on this, and we asked her to summarise the main results:

Alice: consistently migrant children appear to have worse outcomes in communicable diseases than the host population, which is actually consistent with what happens in adult populations. When you look at mortality, the results are much more divided and inconsistent. But often the causes that are selected in those studies are either communicable diseases or external causes, so injuries and accidents, causes where we might hypothesise that migrant children would be at higher risk than the host population. And really the number one outcome of my systematic review is that there is a paucity of data on these groups of children and the data that exists is almost exclusively from high income countries, and often fails to disaggregate by different paediatric age groups and by different migrant subgroups.

Susanna: For example, gender breakdown is almost inexistent in data regarding migrant youth. The data that exists may also be a huge underestimate, because it often takes into account only people who are registered in a country:

Alice: almost all studies in any setting only take account of people who are documented in some way, who are known to authorities. There are very, very few that address undocumented migrants in any setting. So I think we just have no idea of the scope or scale of that problem. And part of that is a political decision to ignore that, because we are absolving ourselves of responsibility if we are not recording those deaths.

Susanna: Regarding unaccompanied children, I conducted a review specific for their health impacts and I talk about this with Alice:

Susanna: Among the health challenges that I found many were related to their migration journey like nutritional deficiencies, or dental caries or low vaccination coverage in terms of physical health. And then also many mental health challenges. What's your experience in working clinically, with unaccompanied asylum seeking children and what do you think are the key requirements of this?

Alice:  I had done a job within my paediatrics training in community paediatrics where I had lots of consultations with these young people. And I was really shocked at the high level of need. I myself was given very minimal training. There were very limited resources. The assessments were extremely rushed. Usually there weren’t translator facilities and we were often asking young people to translate for each other or to key workers to translate for them. And the medical plans we did make frequently seemed to not be followed up and there was a lack of accountability going forward.

Susanna: Following up on this need, Alice worked with a group of other paediatricians on a pathway set up by Dr Allison Ward in Camden, specific for unaccompanied asylum seeking children. She talks about this project:

Alice: The idea of that service is that it offers a much more comprehensive, intensive and joined up service for unaccompanied asylum seeking children. Taking that project forward, a key point has been that our work has been informed by the young people themselves. And one of the key things that's come out of that involvement has been moving towards a trauma informed care approach, where we recognise and seek to acknowledge the trauma that these young people have been through and actively avoid re traumatizing. In terms of the medical service provided, one of the focuses is increased mental health support and we have a mental health practitioner sitting in on all initial medical assessments. We also have universal infectious diseases screening.  We found that if universal screening was undertaken, 41% of these young people had an infectious disease warranting treatment.

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Susanna: Although there are good examples of appropriate efforts being done for migrant children, one of the main challenges of addressing their health is to scale these examples of good practices to a national and international level.  For example, in a round table discussion that I conducted between different professionals who work with unaccompanied asylum seeking children, they highlighted how there was not a national coordination of services for them, rather they were all services which originated bottom-up. With both Alice and Delan, we discuss how one of the main barriers to this expansion of services comes down to the political attitude towards migrants:

Alice: I think it's a very challenging time to be a migrant in the UK. And obviously, our work as professionals is made more challenging by the political situation. For example, on arrival an unaccompanied asylum seeking person might be picked up by the police, and that might often be quite a hostile interaction and even aggressive. So, our biggest challenge in terms of working as paediatricians is trying to, I suppose, make clear to the young person that we do have their best interests at heart. That for example, if they made disclosures to us around physical or sexual assault and abuse, which is a huge issue with this population, that they will be believed.

Susanna: In fact, one of the main challenges of working as health professionals with migrants and migrant children is to establish trust, since they may not distinguish initially between the different profiles of authority in a different country, especially if they do not speak the language and if they have been direct or indirect victims of racism. On this topic, Professor Delan Devakumar is conducting a Lancet Commission on racism and child health, and we asked him about it:

Susanna: I guess racism is a broader topic that doesn't only impact migrants, but I was wondering if you could tell me a little bit about the intersection between racism and migration and how that has to do with the impacts on health.

Delan: So, racism, this kind of ideology that treats people differently according to their identity. And I think with with migrants there is I guess, the idea of xenophobia which is hatred towards people because they are a foreigner. And certain migrants are treated one way whilst other migrants are treated a different way. And there's often a racial undertone to this form of discrimination that certain migrants face. And it's a big determinants of health. And it's one of the big reasons why migrants face perhaps direct forms of violence or abuse, but also the indirect forms, a way a health system might be set up, that excludes migrants, that excludes migrant children as well. These are forms of structural racism that can lead to poor health.

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Emeline: There is a lot to do and to work on regarding migrant women and child rights and health.  For migrant children, this work has to start by listening to these young people. We ask Alice whether the voices of children are heard enough in research and service development:

Alice: The short answer is absolutely not. I think my personal opinion is as a society we have stigma and prejudice around hearing the voice of the child. We have a tendency to only see children in terms of an extension of their parents. And we also stigmatise and even blame children for behaviour that is entirely consistent with their developmental level.

Emeline: A starting point in thinking differently about these children and teenagers is to not see them as a problem or issue to solve, but as a responsibility we have as humanity towards younger generations:

Delan: we should go back to the point that often, children are healthy, that children do well. migrant children, that children who are forced to move, they do very well in the settings that they move to. They tend to be at higher risk of certain illnesses and I think that's what we need to think of and take care that we are identifying the children who are struggling. And to support these children because migration is, as I said before, it's normal. People always move, they will move.

Emeline: A shift in social attitudes towards migrants is beneficial to societies as a whole, particularly within the turn to nationalism and conflict that we are witnessing in many parts of the world. To finish, we asked Delan if he thinks it is possible to embrace diversity whilst maintaining cultural heritage:

Delan: Yeah, I think it is. It’s a little bit how you talk about migrants in the ways they’re coming here. They’re not coming here to take things away from you, to steal things from you. They are here to make your society, your environment better.

Susanna: We couldn’t agree more. Migration will continue to occur and with it the health impacts that are broader than we were able to cover in this podcast. We added links to publications of our research and that of our guests, encouraging listeners to dig deeper, and to think further how we want to shape societies for the years to come.

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Emeline: For the creation of this podcast, we thank Alice, Akanksha, Delan and Laura for providing their insightful time into their topics of research. We thank Professor Jonathan Wells and Michelle Heys and the UCL Institute of Child Health Global Health Initiative for the funding and the podcast editor Sam Gomberg. We are Susanna Corona and Emeline Rougeaux, and we thank you for listening.