Population Mobility and Health:
An Overview of the Relationships
Between Movement and Population Health
Brian D. Gushulak and Douglas W. MacPherson
The health of individuals and populations is determined and influenced through the complex relationships
between many factors. Travel, migration and mobility can,
depending upon the circumstances, play an important role
in health outcomes, for both individuals and the community at large.
The health of travelers, migrants, workers and other
mobile populations is an area of increasing interest for
many medical and health providers, researchers, educators and policy-makers.1 As the world becomes more
integrated in terms of communication, finance, travel,
commerce and education (a process often labeled globalization),distances and frontiers that once provided limits
to travel and mobility have become increasingly less
important. More people are mobile, the reasons for their
mobility are becoming increasingly more diverse, and the
demographic make-up of these mobile populations is less
uniform.2
As a result of this diversity, knowledge and awareness of health outcomes for mobile populations can often
be limited to what has been acquired from a specific
mobile group. For example, travel medicine providers may
traditionally deal with outbound travelers, humanitarian
workers primarily deal with displaced or refugee populations, and occupational health practitioners often see
migrant workers. Despite the differences in the characteristics and nature of these groups, there are common
health factors related more to the nature and process of
mobility than to the specific population itself. This paper
will attempt to describe those common factors and propose a simplified framework approach to the consideration of mobility-associated health outcomes.
Human movement and mobility have long been recognized as important factors that can affect health and
well-being. Early historical relationships between mobility and health and the attempts to manage or influence
these events were primarily focused on infectious and
communicable diseases.3 As the volume and nature of
human travel and movement have expanded, interest in
the health of mobile populations has increased. Concerns
regarding health and mobile populations now extend to
the study of accidental injury, chronic disease, reproductive
health, maternal–child health, women’s health,4 and mental and psychosocial health.5
The global matrix of health, well-being, travel mobility and population dynamics is complex, and many of
the influencing factors are interrelated. However, it is
possible to consider these complicated interactions in a
simple organized framework.
The relationships between health and population
mobility can be described in terms of two major processes. The first is the process of mobility and movement, which is composed of three components. The
second principle is that of disparity. Each of these major
factors has an intrinsic series of corresponding influences
and effects on the health of the traveler and the broader
community.
Brian D. Gushulak, MD: Director General, Medical Services
Branch, Citizenship and Immigration Canada, Ottawa;
Douglas W. MacPherson, MD, MSc(CTM), FRCPC: Medical
Services Branch, Citizenship and Immigration Canada,
Ottawa; Associate Professor, Department of Pathology and
Molecular Medicine, Faculty of Health Sciences, McMaster
University, Hamilton, Ontario, Canada.
This paper was prepared in a personal capacity; the views
expressed are those of the authors and are not to be attributed to the Department of Citizenship and Immigration or
the Government of Canada.
The authors had no financial or other conflicts of interest to
disclose.
Reprint requests: Brian Gushulak MD, Director General, CIC
Medical Services, Third Floor, 219 Laurier Avenue West,
Ottawa, Ontario, Canada K1A 1L1.
J Travel Med 2004; 11:171–178.
171
172
The Process of Movement and Mobility
The process of mobility consists of three related but
distinct components.
The Premovement Phase
The health characteristics and mobility-related outcomes for an individual or a population will be based on,
and fundamentally related to,the state of health of the traveler before the movement. Premovement health conditions will reflect the genetic, physical, environmental,
personal and population health characteristics preexisting at the place of origin of the mobile traveler (Table 1).
As a result of these preexisting factors, the incidence
and prevalence of illness and disease vary widely across
the world.6 Additional influencing factors at the place of
origin of mobile populations are the social and cultural
aspects of health and well-being.7 Those include such
factors as access to health care services,the role of health care
providers, and considerations of health maintenance practices. Finally, preexisting levels of poverty, accommodation, and education, and the availability of preventive
health measures such as immunization, can significantly
affect health.
The state of health, both personal and community,
in the pretravel phase is an important predictor of subsequent health outcomes for mobile populations.
The Journey Itself
The movement process itself, independent of the
reasons behind the population’s mobility, can have major
implications for health (Table 2).
First, there are the direct physical risks of the journey. Accident and injury can be negative health outcomes
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 1 1 , N u m b e r 3
related to this phase of mobility. For many travelers, such
as business and tourist populations, these events represent the major health risks for the actual movement
phase.
There are, however, additional risks for other
populations who are less able to control or modulate
the type of travel that they may undertake. Examples
include refugees, displaced populations or those irregular or illegal travelers and migrants who cannot access
commercial routes of entry. Such individuals may be
deprived of basic necessities such as food, water, emergency health care, security and personal safety during
the movement phase. Additionally, these individuals may
be exposed to unhealthy environmental factors,8 violence, and dangerous means of transport. Adverse health
outcomes are more commonly observed in the most vulnerable groups.
Depending upon the situation and the characteristics of the mobile population, vulnerable groups may vary.
In some situations, the elderly or the very young may be
vulnerable. In other locations and environments, vulnerability may be a factor of preexisting illness or poor
nutritional status, where travel can interrupt or affect the
ability to receive care. Finally, there are situations in which
social conditions, including risks of violence or crime,
may define vulnerable cohorts of mobile populations, as
is seen in sexual violence against women.
Following the completion of the journey, mobile
populations composed of these vulnerable groups can
create significant service demands at their destinations.
Refugee and displaced populations represent communities
that require specific attention in terms of mental and
psychosocial illness. Additional challenges are introduced
when the skills and experience to effectively deal with
Table 1 Premovement Factors that Influence Health
Status
Outcome
Incidence and prevalence of infectious diseases
Transmission of /or acquisition of disease during journey or
on arrival33
Incidence and prevalence of noninfectious disease/illness
Introduction of individual/population with different health
characteristics/needs into the receiving health care system34
Social factors (education/housing/poverty)
Baseline levels of health status that can increase the risk of
illness/disease during travel, and affect access to health
services on arrival
Environmental factors (geographic, weather, toxic, political)
Background level of nutrients, toxins, violence, trauma
(physical/psychosocial), and natural events (extreme
temperatures,35 storms, fires, earthquakes)
Status of local health and social services
Availability, accessibility and affordability of existing health and
social care services. The institutional and noninstitutional
capacity to respond to health promotion, prevention and
intervention population requirements
Cultural factors
Expectations and utilization of health services/concepts of
disease and ill-health
Gushulak and McPherson, Population Mobility and Health
173
Table 2 Movement Factors That Influence Health
Effect
Outcome
Process of movement—regular or irregular: regulated movements pose different risks to the migrant than irregular
movements (smuggling or trafficking)36 due to the mechanism of travel, environmental exposures, interactions
with border and civil authorities, and specific coercion
and violence associated with illegal activities
Accidental injury or death37
Incarceration38
Exposure (thermal, dehydration, high altitude, drowning)
Violence (physical, psychological, sexual)
Post-traumatic stress disorders
Duration of movement—extreme situations of internal and
international displacements
Temporary and permanent refugee camps;39 acute to chronic
exposures to nonendemic health risks and new health
determination conditions
Social and health program impacts
Lack of, delayed onset of or interrupted medical care, treatment or prevention programs (periodic health examination, dental, visual acuity, vaccination)
these populations may not be widely found in health care
providers at the destination.
locations and more rapid travel between these locations.
One of the consequences of this rapid movement has been
the increased potential for ill individuals with travel- or
movement-related illness to pass through border or frontier health/quarantine services undetected,presenting later
at another location with symptomatic disease.Primary and
secondary health care providers,therefore,are increasingly
likely to encounter movement-related illness that historically has been rare or dealt with at larger centers.9
The Arrival Phase
The type, components and characteristics of local
health services at the travelers’ destinations have important effects on health outcomes. The level and capacities of health services have impacts whether they are found
at sites of permanent reception or sites of temporary
sojourn for mobile populations (Table 3).
Once again, health outcomes are related to and influenced by the physical, social, educational, economic,
medical and cultural aspects at the location where the travel
or movement ends. Obviously, the time at which these
outcomes manifest themselves will vary with the specific
conditions, but it can be generally stated that those who
have been most compromised before or during the mobile
phase remain the most vulnerable at the destination.
An important demographic consideration in managing
the health of arriving mobile populations has been the
increasing distribution of potential interfaces with health
services. Modern travel and transportation technologies
have allowed both easier access to previously isolated
The Effects of Disparity
Health parameters and outcomes differ widely across
and between regions of the world. Large variations persist even among states with similar national statistics in
terms of financial and social standards. Disparity is perhaps the most important factor in the relationship between
mobility and health. When health conditions and
environmental factors are similar between the origin and
destination, the only adverse health outcomes are those
directly related to the journey itself, as defined above
(Table 4).
Table 3 Arrival Factors That Influence Health
Effect
Outcome
Economic
Impacts on access to health care, nutrition, housing and other
social services impacting on health (education, employment)
Legal status on arrival
Impacts on rights and freedoms;40 potential for interaction with
civil justice authorities, including arrest and detention
Personal behavior—acquired41
Risk-taking,42 abuse,43 violence, injury, death
Cultural practices44
Expectations45 regarding access to and use of services
Host destination environment and ecology
Environmental culturalization and accommodation related to
variations in weather, urbanization, toxins and pollutants
Host destination communities for social integration46
and settlement
Physical, psychological and social well-being
174
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 1 1 , N u m b e r 3
Neutral Disparity Travel
Neutral disparity movement is the most common
health experience for the majority of mobile individuals. Hundreds of millions of people travel annually within
their own nations or between destinations where health
characteristics, practices and environments are similar or
identical. Consequently, in terms of health, these movements are neutral.
In situations where the journey is between similar
health environments, mobility-associated health outcomes
reflect the personal characteristics and behavior of the
traveler as well as the background health risks associated
with the conveyance. Examples of the former include the
use of personal protection devices such as seat belts or
motor cycle helmets, or operating a conveyance while
impaired. Health risks associated with the conveyances
themselves vary with the mode and type of travel and
relate primarily to accidental death and injury.
Motor vehicle and transportation accidents are the
major sources of mortality, morbidity and negative health
outcomes in this context. Although they may be considered to be mundane risks,it should be noted that the population impact due to accidents of this type have significant
economic and public health effects.In some situations,particularly in the developing world, these events exceed the
cumulative impact of the more traditionally expected travel
and mobility health risks10 such as tropical disease.
Travel and Mobility Between Disparate
Risk Environments
The amount, availability and quality of resources
directed to the protection of and maintenance of health
varies between regions and nations. Throughout the
world, in developed as well as developing regions, health
officials attempt to deal with competing priorities. This
disparity in health factors, prevention,11 treatment and
control measures is often associated with an increased
prevalence of illness and disease, both noninfectious and
infectious. Many of these disparities are more pronounced
among poorer and rural populations.12 Consequently, the
movement of people between these areas of disparate
health indicators, often between the developing or rural
world to more developed or urban areas, creates a functional bridge between these differences.13
In a time of expanding and more rapid travel, there
is more movement that results in the bridging of health
disparities. Individuals and populations can easily journey between locations or regions where certain diseases
are of high prevalence to destinations where the same disease is rare, or has been eliminated. This is commonly
seen in the case of travelers from regions of the world
with high levels of tuberculosis14 or in travelers moving
from areas where vaccine-preventable diseases continue
to circulate.15
Travel between these disease disparities, which are
commonly referred to in migration health as prevalence gaps,
can pose significant challenges for those who deal with or
provide public health assistance to mobile populations.
Depending on the jurisdiction and location, the arrival of
long-staying mobile populations from regions with different disease patterns can produce complicated public
health responses.Some diseases,such as tuberculosis or certain vaccine-preventable diseases,generate legally mandated
public health responses in destination countries;others,such
as infections that are resistant to several antibiotics, or that
are complicated, such as HIV, can be costly to treat.
It is important to note that mobility of populations
across prevalence gaps can be a bi-directional process.
Travelers and mobile communities may cross gaps that
introduce them into higher- or lower-risk environments.
Consequently, population mobility may create situations
where the mobile community itself can be at risk, as
observed in travel from nonmalarious to malarious areas.
Conversely, some mobile cohorts may pose a risk to
others, as is observed with the importation of uncommon
illnesses or diseases that have been controlled or eliminated at the destination.16 Additionally, it is important to
note that prevalence gaps are not restricted to infectious
Table 4 Influences of Disparity on the Health of Mobile Populations
Disparity
Outcome
Travel between similar health environments
Related to the conveyance only (accident)
Travel between disparate risk environments
Movement towards increased risk
Movement towards decreased risk
Importation of illness/increased exposure to illness after arrival
Greater impact in mobile cohort
Greater impact in receiving population
Travel between disparate health systems
Altered access to or use of services.47 Depending on the direction
and nature of the mobility, the result for the individual may be
improved or worsened (i.e., access to complicated care in
movement towards the more developed world may provide
increased access to HIV treatment, while the same journey
could be associated with a delayed or less efficient diagnosis of
malaria due to unfamiliarity with the disease)
Gushulak and McPherson, Population Mobility and Health
diseases. The rates of many chronic diseases, including cardiovascular, oncologic, neurologic and endocrinologic
disease, vary between regions of the world. Although these
factors are of limited concern for short-term mobile
groups such as tourists or business travelers, they are
significant for long-staying mobile populations.
Travel and Mobility Between Disparate
Health Systems
It is traditional to think of the relationship between
population mobility and health in terms of simple differences in disease incidence or prevalence levels. This
is most often true in the practice of travel medicine or
situations of immigration or refugee medical screening.
However,an increasingly important aspect of disparity
that influences health outcomes is the disparity within
health systems themselves. The nature and use of health
care services,hospitals,clinics,doctors,pharmaceuticals and
other medications can differ significantly.Additionally,there
can be profound differences in how these services are allocated,accessed or reimbursed.These differences have been
shown to influence how and for what reasons mobile populations seek or utilize health care.
The Implications of the Relationships Between
Health and Population Mobility
The relationships and associations between population health and mobility are not only important for the
practitioners and service providers directly involved with
a particular mobile community. There are also important
lessons for the decision-makers who are considering the
future needs of health care systems. As travel, migration
and international work increase in volume and diversity,
there will be longer-term implications that will influence
the demands for and types of health services necessary
to manage these issues.17
Many of these relationships are already beginning
to exert important influences on health policies, planning and practice.18 It remains important in this context
to note that the impacts of mobility on health can be
positive, neutral or negative for the individual and the
receiving population. Depending on the health or social
measurement, these influences may be mixed for both
the migrant and the host destination.19
Examples of how mobility health issues are addressed
across the spectrum of affected populations are both
diverse and complex.
Protecting and Enhancing the Health of
Mobile Populations
One of the most efficient methods of supporting
the good health of mobile populations is the prevention
175
of illness or disease. Prevention is one of the most
traditional of travel medicine practices. Pretravel immunization, delivery of chemosuppressive medications,
advice, education and instruction in preventing illness
and sustaining health are provided to certain mobile populations. Tourists, visitors and business travelers comprise
a large component of the recipients of these interventions, but other groups are also traditional beneficiaries
of these services. Health interventions of this type are
also common in the military, international businesses,
humanitarian organizations and business enterprises
where travel or mobility is common or required as a condition of employment.
Traditionally,efforts at protecting the health of mobile
populations have centered on infectious diseases. This is
due to both their communicability and the availability
of immunizing, preventive or therapeutic agents to modulate or reduce adverse outcomes.
Regulatory or legislated requirements to intervene
in certain situations, particularly those involving international travel, have provided additional support for these
types of intervention.
As other mobility-associated noninfectious disease
health risks have been more widely recognized and investigated, they have received increased attention. The
prevention or modulation of noninfectious illnesses, accident, injury and ill-health is now a routine approach in
the health care delivery practices in some communities
with numbers of mobile individuals.
Reducing the Impact of
Mobility-associated Illness
Some mobility-associated health concerns,e.g.,occult
or asymptomatic infections, and psychosocial or mental
health issues, may not be prevented or easily treated. Not
all mobile groups have access to or utilize voluntary predeparture services. Mandated or required interventions
are primarily related to a limited number of infectious
diseases regulated under international agreement, as seen
in yellow fever immunization. Other required medical
interventions are observed in the case of immigrants,
refugees and transient workers who may need medical
assessment related to their travel status.
Approaching and managing mobility-associated illhealth and disease on arrival is another major undertaking.
Best considered as traditional travel medicine in reverse,
activities of this sort involve the detection and treatment
of illnesses and diseases that may be more commonly
found in mobile populations.20
Historically, endeavors of this type have been directed
at particular groups of arriving travelers.21 The scope of
activity ranges from the active mandated screening of particular populations, such as migrants22 or workers, to the
passive delivery of health recommendations for those
176
anticipated to have higher risks of ill-health as a consequence of their mobility.23
Current efforts in this field of health service provision are changing the scope and nature of these practices.
Recent situations involving large numbers of refugees and
displaced populations have produced organized strategies
for reducing the health risks in these populations in a more
effective and efficient manner. Epidemiologic investigations in communities of migrants and mobile populations
are further defining areas of increased risk and corresponding preventive strategies.24 Additionally, advances in
medicine,pharmacology and vaccine production have made
it much easier and cost-effective to intervene earlier in the
process and provide more robust intervention.
Expanding the Capacity of Health Systems to
Meet the Challenges
In spite of the two above-noted undertakings, there
are large numbers of mobile individuals who will arrive
at a destination with health concerns and risks related
to their movement. They will have illnesses or diseases
that were not amenable to predeparture intervention or
affected by programs designed to limit or reduce the
importation of ill-health. Many of the travelers with these
health problems will be long-staying or permanently moving populations.25 Their health will affect and influence
the health systems in the immediate, medium and longer
term.
Increasing population mobility is creating a number of challenges for and demands on health systems in
both the public and private sectors. Growing numbers
of individuals are new arrivals in their current place of
residence. Some of these mobile populations are transient,
remaining for relatively short periods of time. Others
reside for longer periods and then move on or return to
their homes, while a third group remains permanently
after travel.
Given the rapid pace of change in the world, the
influence of a diversity of factors on the health and wellbeing of mobile populations is a dynamic process. Specific
lessons and experiences gathered from one cohort or
population might not be directly applicable or transferable to other communities. However, general principles
gleaned from the management of ill-health in mobile populations will be useful to health care providers as they deal
with the health concerns of increasingly diverse patient
populations.26
For the present and foreseeable future, these populations will grow in number, and there will be corresponding impacts on the levels and types of health and
medical services that they require on arrival and into the
future. To better manage these demands for service, a
variety of options and approaches is required. Health
providers need to be better trained to recognize,
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 1 1 , N u m b e r 3
diagnose and treat illnesses and diseases that have been
previously uncommon or unusual but which may become
more widely encountered as a result of population mobility.27 All aspects of the health care systems may need
increased capacity to more effectively deal with the
linguistic and cultural aspects of health care delivery.28
Policies and programs that support or enhance access
to both preventive and therapeutic health care services
for nonmainstream mobile populations will need to cope
with the disparate health needs and utilization patterns
of mobile populations.29 Finally, there should be wider
distribution of the knowledge and results produced by
ongoing research, surveys and studies on mobile populations’ health needs.30 The improved dissemination of
relevant information and knowledge of the relationships
between health and population mobility can be easily
facilitated by modern information technology tools.
Summary
Approaching health outcomes in mobile populations
on the basis of the framework described above can lead
to greater synergy of effort and knowledge exchange.
Health practitioners, service providers and others who
work with mobile populations or cohorts have access to
or generate information and understanding that may be
of use to others who interact or deal with different mobile
communities.
The practical tools that will assist in improved information gathering and sharing, knowledge transfer and
education will also be important in the development
of programs and policies necessary to more effectively
manage the health challenges associated with population mobility.31 Examples of this approach as currently
practiced in travel medicine include the Geosentinal
Network for Global Surveillance.32 Similar networks and
nodes involving national immigration medical screening
authorities could improve the analysis and distribution
of relevant information. Such targeted research and analysis of issues of current interest will be useful in the broader
understanding of both the individual and community
health of migrant populations in a globalized and rapidly
integrating world.
Priorities for action related to the recognition of the
growing importance of health and population mobility
extend across several health sectors. They range from
policy development to actual health care delivery. In concrete terms, policy activities include the recognition and
consideration that a rapidly diversifying patient population may require reconfigured or redefined health program delivery services. Those services will progressively
need to reflect the language, culture and history of the
patients who, because of population mobility, are an evolving population. At the same time, improved recognition
Gushulak and McPherson, Population Mobility and Health
of the issues described in this paper can assist in the modernization of regional and international health governance
and regulatory authority considerations. Many of the
screening practices now employed by immigration receiving nations are dated in both their scientific and technical aspects.
Finally, the appreciation of the growing impact of
population mobility on health and diversity can assist in
the development of training material, educational curricula and services that are targeted at mobile populations in both destinations and donor regions for migrants.
That information will assist national and local health agencies and providers as they balance the health needs of a
patient spectrum that spans international skilled workers, immigrants and more “at-risk” migrant populations
such as refugees, asylum seekers, refugee claimants, and
humanitarian movements. From an integrated and harmonized method of considering health and mobility, consistent approaches and strategies can be created, and these
will eventually turn into best practices that can be widely
applied.
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