Migration and health
Jonathan Santiago takes an in-depth look at Haitian Migration to the Dominican Republic
Figures over the last twenty years continue to demonstrate the increase of South-South migration - poor people from poor countries moving to less poor countries. (1) The burden of these migrants is often met with indifference as developing countries struggle to provide social goods and healthcare for their own citizens. Potential employment may blind migrants to social tradeoffs. While globalization continues apace and free markets influence labor, many migrants headed to and from developing countries will continue to search for employment only to find their health and human rights compromised.
Various studies have documented health disparities between migrant families and resident populations. (2) Other reports have focused on migrants as potential vectors for sexually transmitted infections (STIs) and HIV. (3) (4) However dire the health of migrants may be, it is imperative that health practitioners view their disparate health outcomes as one issue connected to a complex web of political and socio-economic determinants. A deeper look at the history of Haitian migration to the Dominican Republic (DR) will illustrate how the health of migrants is directly affected by such factors. Although bearing many parallels with migrants in similar contexts, this particular case is embedded in a saga of history, politics, and society that is as unique as it is tragic to those involved.
Haitian migration to the Dominican Republic
Push and pull migration factors ranging from politics to employment have led to a steadily increasing number of Haitians and Dominican-Haitians (Dominicans of Haitian descent) in the DR. With the rise of the sugarcane industry in the 20th century, cheap labor was needed from Haiti to reach production quotas. Employment contracts between both countries facilitated the migration of workers. Economic and political instability in Haiti stretching from the Duvalier dictatorships to the revolutions surrounding ex-president Jean-Betrand Aristide have also contributed to the rise in migration. Estimates of Haitians and Dominican-Haitians living in the DR range from 500,000 to 1 million. (5) Although largely undocumented, this population accounts for 5-10% of the total population.
As result of the sugar industry’s dependence on migrant labor, the majority of Haitians and Dominican-Haitians in the DR live within close proximity to sugarcane fields. The residences where workers live are communities called bateys. Originally designed to house male migrants for seasonal work, bateys have become permanent settlements for entire Haitian families and their descendants. While the 20th century saw the rise and decline of the sugar industry, fewer resources were made available for workers and batey residents. Accusations of modern-day slavery and harsh treatment of laborers have brought batey issues to the forefront of Dominican policymakers while also increasing nationalistic sentiment in the DR.
Health of Haitian migrants and their descendants in the DR
The negative health outcomes of Haitians and Dominican-Haitians living in the DR are directly related to political and socio-economic realities. These upstream factors create an interconnected and complex web leading to health disparities. Despite the relation between each factor and health, it is important to understand the interconnectivity and relationship between all factors. Three variables will be examined to better understand their effects on the health of Haitian migrants and their descendants living in the DR.
Politics and legislation
Migration legislation is a major impediment to improving the Haitian situation in the DR. The Dominican government does not issue birth certificates to children born in the DR if their parents do not have a cedula (national identification card). Without a birth certificate, a person can not receive his or her cedula. As a result, generations of Haitian families remain undocumented and without an official identity despite having been born and raised in the DR. Consequences for those without documentation have a direct effect on one’s education, ability to find employment, and access to social benefits - particularly government programs aimed at improving access to healthcare.
Because of their original role as migrant housing, bateys have traditionally been regarded as isolated communities not entitled to the political rights and protections afforded to the Dominican population. With the liberalization of the sugarcane industry in 1999, private enterprises no longer provided the minimal social and health benefits once made available by the government. (6) Consequently, health and sanitary conditions have deteriorated. For impoverished migrant communities lacking the social cohesion to work together, batey residents are left to fend for themselves in an unpromising situation.
Wealth disparity
Annual per capita income in the DR is approximately 5 times that of Haiti (US$8217 vs. US$1663), thus serving as a major factor increasing Haitian migration to the DR. (7) Income gaps between Dominicans and Haitians in the DR are difficult to quantify since a large number of the latter work in the informal sector. Similar to other migratory experiences, available jobs tend to be those traditionally held by immigrants and viewed as low paying - such as sugarcane cutting and construction. Much of the employment in these sectors does not require documentation (birth certificates, cedulas) and many times is operated by employers who underpay for migrant labor.
The lack of income in bateys has led to a thriving trade alluring young women to the commercial sex industry. The potential consequences for commercial sex workers include risk of HIV infection, domestic abuse, and social stigma. Health statistics are staggering. HIV prevalence in bateys is 5-10 times the general population (5-14% vs. 1-2%). (8) (9) Not only is the health of commercial sex workers in jeopardy, but so are the health of their spouses and families upon their return home. Many migrants are also potentially exposed to STIs and HIV as they participate in the commercial sex trade. Aside from the conventional version of the sex trade, many women in bateys are seen as buscavidas. Literally “life finders”, buscavidas make up an informal commercial sex trade as women endure sexual relationships with men who can provide for personal and family needs.
Racism and discrimination
Unlike many countries of Latin America who freed themselves from Western Europe, the DR gained its independence from Haiti after 22 years of rule. While Haiti became the second country in the Western Hemisphere to gain independence in 1804 after the largest recorded slave revolt, the revolution spread east to free the entire island of colonialism. Historical revisionism remains central to current nationalistic views. Today’s harsh treatment of Haitians and Dominican-Haitians can be directly traced to views of Haitians as violent insurrectionists and occupiers instead of liberators of the Spanish-speaking part of the island. In addition to the national story of independence, former dictator Rafael Trujillo exploited racist undertones to strike fear into the country. Dominicans were socially constructed to be of Spanish descent, Catholic, and Spanish-speaking while contrasted with Haitians who were of African descent, worshiped Voodoo gods, and spoke Haitian Creole. Like other migrant groups, Haitians are viewed as scapegoats for economic and social troubles. A massacre in 1937 killing 17,000 to 35,000 Haitians saw the culmination of anti-Haitian sentiment.
Racial discrimination affects deliverance of healthcare in the DR. Poor access and care for Haitians and Dominican-Haitians at public hospitals and clinics have been documented. (10) In addition to these prejudices, government health initiatives and campaigns largely ignore bateys due to their isolation and common misconceptions of Haitians as undeserving and culturally inferior. Although NGOs have filled a part of the gap, a worsening health crisis will broaden if the government does not assume a more prominent role.
Conclusion
Although one may argue that countries have a responsibility to those contributing to the national economy, improving the health of South-South migrants may not necessarily include mandating poor countries to bear the extra burden. Supporting measures related to improving migration policy and international relations may reduce animosity and misunderstanding between countries and migrants. Policy directed at improving economic conditions of neighboring countries can also provide employment opportunities to curtail migration.
Understanding how migrant health disparities are a function of political and socio-economic factors is central to reducing unequal health outcomes. Health practitioners cannot and will not begin to make sustainable changes if these upstream factors are not addressed with political conviction and solutions. Supporting equity oriented legislation, stopping and reversing the widening gap between rich and poor, and seeking to acknowledge and transform discriminatory dogma are policies that will require a shift in paradigm from alienation and fear to equity and inclusiveness.
Jonathan Santiago
University of Washington
Global Health Department
Seattle, Washington
USA
jsanti25@gmail.com
(1) Ratha D, Shaw W. South-South migration and remittances. World Bank Working Paper 102, Washington DC: World Bank, 2007.
(2) Loue S. Handbook on immigrant health. New York: Plenum Press; 1998.
(3) Brummer D. Labour migration and HIV/AIDS in Southern Africa. International Organization for Migration Regional Office for Southern Africa. 2002.
(4) Kulis M, Chawla M, Kozierkiewicz A, Subata E. Truck Drivers and casual sex: an inquiry into the potential spread of HIV/AIDS in the Baltic region. World Bank Working Paper 37, Washington DC: 2004
(5) Ferguson J. Migration in the Caribbean: Haiti, the Dominican Republic and beyond. Minority Rights Group International. 2003.
(6) Silie, R et al. Efectos de la privatizacion de la industria azucarera en tres ingenios de la provinica San Pedro Macoris: Porvenir, Quisqueya y Santa Fe. Santo Domingo: FLASCO and CCDH. 2002.
(7) UNDP, Fact sheets, Accessed March 12, 2008. http://hdrstats.undp.org/countries/
(8) Brewer H, et al. Migration, ethnicity, and environment: HIV risk factors for women on the sugarcane plantations of the Dominican Republic. AIDS 1998; 12: 1879-1887.
(9) Koenig RE, et al. Prevalence of antibodies to HIV to Dominicans and Haitians in the Dominican Republic. JAMA 1987; 257: 631-634.
(10) Yanguela, A. Bateyes del Estado: Encuesta socioeconomico y de salud de la poblacion materno-infantil de los bateyes agricolas del CEA. USAID. 1999.
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