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date: 27 January 2022

Migration, Migrants, and Health in Latin America and the Caribbeanfree

Migration, Migrants, and Health in Latin America and the Caribbeanfree

  • Deisy Ventura, Deisy VenturaSchool of Public Health, University of São Paulo
  • Jameson Martins da Silva, Jameson Martins da SilvaSchool of Public Health, University of São Paulo
  • Leticia CalderónLeticia CalderónInstituto Mora
  •  and Itzel EguiluzItzel EguiluzInstituto de Investigaciones Económicas, UNAM

Summary

The World Health Organization has recognized health as a right of migrants and refugees, who are entitled to responsive healthcare policies, due to their particular social determinants of health. Migrants’ and refugees’ health is not only related to transmissible diseases but also to mental health, sexual and reproductive health, and non-communicable diseases, such as diabetes. Historically, however, migration has been linked to the spread of diseases and has often artificially served as a scapegoat to local shortcomings, feeding on the xenophobic rhetoric of extremist groups and political leaders. This approach fosters the criminalization of migrants, which has led to unacceptable violations of human rights, as demonstrated by the massive incarceration and deportation policies in developed countries, for example, the United States under the Trump administration.

In Latin America and the Caribbean, in particular, there have been legal developments, such as pioneering national legislation in Argentina in 2004 and Brazil in 2017, which suggest some progress in the direction of human rights, although in practice drawbacks abound in the form of countless barriers for migrants to access and benefit from healthcare services in the context of political turmoil and severe socioeconomic inequality. The COVID-19 pandemic has exposed and enhanced the effects of such inequality in the already frail health conditions of the most disenfranchised, including low-income migrants and refugees; it has both caused governments in Latin America to handle the crisis in a fragmented and unilateral fashion, ignoring opportunities to cooperate and shield the livelihoods of the most vulnerable, and served as a pretext to sharpen the restrictions to cross-border movement and, ultimately, undermine the obligation to protect the dignity of migrants, as the cases of Venezuela and the U.S.-Mexico border illustrate. Still, it could represent an opportunity to integrate the health of migrants to the public health agenda as well as restore cooperation mechanisms building on previous experiences and the existing framework of human rights organizations.

Subjects

  • Global Health
  • Public Health Policy and Governance
  • Special Populations

Introduction

Being a national or a foreigner is a matter of perspective. One is a national by living in their country of birth or obtaining its nationality. One is a foreigner when living outside that country. From a logical point of view, anyone may become a migrant by settling temporarily or indefinitely in another country. Although such claims may sound obvious, they breach an essential element of the prevailing institutional stance on contemporary migration: the cleavage between us and the others. This cleavage, separating human beings into nationals and foreigners as a relentless criterion of allocating allegedly scarce resources, has prevented the right to migrate from becoming a systematically recognized human right.

Furthermore, migrants’ human rights have been widely neglected, which directly influences their living standards. The denial and neglect of those rights necessarily implies hindering the very recognition of their human condition. Therefore, the first premise of this article is that the health of migrants must be examined under the lens of human rights, which should precede other approaches guided by biomedical, economic, epidemiological, humanitarian, and securitarian biases.

The second premise is the recognition of Latin America and the Caribbean as a locus of emigration and immigration or, more precisely, as a zone of migration flows, including origin, transit, and destination. The region went under successive economic crises, natural catastrophes, and consequential political instability in the second half of the 20th century. Thousands of people left their countries during the military dictatorships in Argentina, Brazil, Chile, Paraguay, and Uruguay, as well as during long armed conflicts in Colombia, Guatemala, Nicaragua, and Peru. Consistent migration flows set in, such as Cubans, Haitians, and Mexicans toward the United States, which made the region a source of flows to the developed world.

Nevertheless, in the 21st century, as a result of highly restrictive policies to human mobility toward the Northern Hemisphere, as well as favorable economic periods in some countries in the Global South, a new dynamic of flows took place. Latin America has thereby become a relevant destination to international migration, particularly that of the South-South axis. The intense mobility in the region poses a challenge to the national healthcare systems, disrupted by years of underfunding, sharpening austerity policies, chronic corruption, and well-known overload from continued omission with regard to the so-called social determinants of health (WHO, 2008a),1 as disturbing figures on food security, education, labor, housing, and sanitation often confirm.

The aim of this article is to offer an overview of migrants’ health in Latin America and the Caribbean from a critical perspective in order to trace and synthesize its essential elements. The article builds on an extensive literature and document review, besides the authors’ experience with social movements, composed both by migrants and health professionals.

The section “The International Legal Framework on Migration and Asylum” demonstrates that migration flows are still bounded by a modest and quite ineffective legal framework. The section “The Recognition of Migrants’ Right to Health by the UN System” specifically deals with the emerging international regime of recognition of migrants’ right to health. Further, the section “Competing Approaches to Migration and Health: Securitization vs. Human Rights” presents the tensions between these approaches to migration and health, underlining the peculiar securitization of migration. The article further outlines the advances and shortcomings in Latin America and the Caribbean, focusing on national legislation, policies, and international cooperation. Lastly, the article explores the repercussions of the ongoing COVID-19 pandemic and the pitfalls and opportunities unfolding during the crisis. In the final remarks, the article summarizes and underscores some perspectives in the light of the COVID-19 health crisis as well as desirable pathways to governments in the region.

The International Legal Framework on Migration and Asylum

Although each state holds exclusive constitutional competence to rule on the entrance and stay of people in their territories, an international framework on migration and refuge has been historically consolidated in multilateral and regional spheres. The legal regimes governing migration and refuge should not be confused. In this chapter, the term migrants designates people seeking temporary or permanent residence in another country, for several reasons, most frequently in the search of work opportunities; and refugees refers to those who leave their country of residence based on a well-founded fear of persecution (political, ethnic, religious, etc.), besides the occurrence of grave and systematic violation of human rights, according to the wider interpretation of asylum promoted by the Declaration of Cartagena.

Yet one must recognize the overlapping and, at times, political disputes around both concepts. Their use in this article is based on the need to distinguish the norms in force and display statistical data oriented by this cleavage. However, the sheer split between migrants and refugees may as well conceal the fact that circumstances such as climate change and extreme poverty, for instance, do not leave much room for the choice between staying or leaving (Cernadas, 2016). In that sense, the expression “human mobility” can more appropriately encompass both migration and refuge and translate the multilayer phenomenon of human displacement across the globe.

In legal terms, the difference between migration and asylum is clear. The International Law of Refugees emerged from the United Nations Convention Relating to the Status of Refugees, signed in 1951, in Geneva, Switzerland, and its additional Protocol, of 1967.2 Stemming from the great trauma after the Second World War, which forced over 50 million people, mostly European citizens, to flee their homes, the convention was ratified by 145 states. All states in Latin America and the Caribbean subscribed the convention, except Cuba and Venezuela.3

The paramount principle of the convention is the non-refoulement, according to which a refugee having reached the territory of a state party to the convention must not be returned to their country of origin but rather protected or sent to a safe third country. The United Nations Refugee Agency (UNHCR) plays a fundamental role in implementing the convention and is quite active in the Americas, despite being chronically underfunded and criticized for underwhelming results.4

In the regional sphere, the most relevant legal landmark is the Declaration of Cartagena on Refugees adopted in 1984. It reproduces the substance of the UN Convention, particularly the non-refoulement principle, urges states to adopt appropriate proceedings to seeking asylum, and highlights the importance of protecting the safety of refugees (Demant, 2013). In 2014, a report by civil society organizations from several states in the region claimed that the access to free-of-charge healthcare to asylum seekers and refugees is guaranteed in almost all countries, in the form of primary care in state-funded healthcare centers, as well as specific support programs for serious diseases and disabled people (Asylum Access, 2014).

Under the auspices of the UNHCR, countries and territories of Latin America and the Caribbean gathered in Brasilia in February 2018 to define the so-called 100 Points of Brasilia, Inputs from Latin America and the Caribbean to the Global Compact on Refugees (UNHCR, 2018a). The document prescribes the promotion of policies and programs of social inclusion to refugees, including expedited issuance of documentation to promote access to a series of social rights, among which are public housing and healthcare systems. In December 2018, the Global Compact on Refugees was adopted in the realm of the United Nations (UNHCR, 2018b). Despite being widely recognized, the regional norms and recommendations related to refugees still face countless hindrances, especially due to scarce funding available to hosting and installation programs for refugees in the region.

Regarding international migration, two multilateral instruments stand out. The first is the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families, of 1990 (OHCHR, 1990). Negotiated in the scope of the United Nations, it came into force only in 2003 with 56 member states.5 All countries in South America subscribed to the convention, except for Brazil; in Central America, Guatemala, Honduras, Jamaica, and Saint Vincent and the Grenadines ratified it; and in North America Mexico is the sole signatory. The low membership of the convention, compared with other international treaties, is most likely due to the explicit recognition of a wide range of rights for undocumented or irregular workers, including in health-related topics.

According to Article 25 of the convention, “all the migrant workers shall enjoy treatment not less favourable than that which applies to nationals of the State of employment in respect of remuneration and other conditions of work, among which safety and health.” Article 28 also states that “migrant workers and members of their families shall have the right to receive any medical care that is urgently required for the preservation of their life or the avoidance of irreparable harm to their health on the basis of equality of treatment with nationals of the State concerned,” regardless of their migration status.

In December 2018, during an intergovernmental conference in Marrakech, Morocco, 164 states adopted the Global Compact for Safe, Orderly and Regular Migration, also endorsed by a UN General Assembly resolution subscribed by 152 member states.6 The non-binding Global Compact had a major resonance and faced harsh criticism from conservative governments, in particular the United States, and xenophobic movements worldwide. Nevertheless, the matter of the compact is rather modest. Whereas it recognizes the migrants’ human rights, it does not stand for a right to migration. Furthermore, despite focusing on the international cooperation in the topic, the Global Compact “reaffirms the sovereign right of States to determine their national migration policy and their prerogative to govern migration within their jurisdiction,” taking into account “different national realities, policies, priorities and requirements for entry, residence and work, in accordance with international law.”

Migration stands among the topics on the 2030 agenda, which has defined the widespread Sustainable Development Goals (SDGs).7 The 17 SDGs inspired further regional initiatives related to migration in Latin America. The Economic Commission for Latin America and the Caribbean (ECLAC) promoted the Mesoamerican Comprehensive Development Plan, convening Mexico, Guatemala, El Salvador, and Honduras, aiming to address the structural causes of migration in the region and ultimately make migration a safe option, instead of a forceful drive of hazardous mobility. This strategic document proposes an approach to mobility as a matter of human security, encompassing human rights, public safety and defense, and the means of livelihood for people, instead of addressing it as a phenomenon of national security (ECLAC, 2019).

Both norms related to asylum and migration are covered by the Inter-American System for the protection of human rights, which is made up of two organs: the Inter-American Commission on Human Rights and the Inter-American Court of Human Rights, which monitors the compliance by the member states of the Organization of American States (OAS) with the obligations they have undertaken. Since 1996, the commission has deployed a Rapporteurship on Internally Displaced Persons and the Rapporteurship on Migrant Workers and Members of their Families. Among other functions, the special rapporteur on the rights of migrants issues reports and specialized studies with recommendations directed to member states of the OAS for the protection and promotion of human rights of migrants and promptly acts on petitions and cases where it is alleged that the human rights of migrants are violated in any of the OAS member states. Its latest report addresses forced migration of Nicaraguans to Costa Rica (IACHR, 2019a).

In 2019, the Inter-American Commission on Human Rights adopted the Inter-American Principles on the Human Rights of all Migrants, Refugees, Stateless Persons and Victims of Human Trafficking (IACHR, 2019b). Among other provisions, Principle 35 of the document reasserts that migrants are entitled to “the highest attainable standard of physical and mental health and to the underlying determinants of health”; and that healthcare cannot be denied due to a person’s migration status or lack of identity documents and that certain groups, such as women, children, and adolescents, may require differentiated care.

Several situations and cases involving the rights of migrants have been taken before the Inter-American system. One of the best-known manifestations of the court was the advisory opinion regarding the “Rights and guarantees of children in the context of migration and/or in need of international protection” (Inter-American Court of Human Rights, 2014), in response to a request from Argentina, Brazil, Paraguay, and Uruguay in July 2011. The limited material and human resources of the Inter-American system, however, does not allow for thorough control of the application of the aforementioned international legal instruments, which remain rather incipient.

This brief overview on the legal framework of migration and asylum does not account for the distorting effect of mounting obstacles posed to regular migration, which fail to discourage the multifaceted and ever-increasing human mobility. Restrictive migration policies are thus ineffective. Instead of hindering the flows, the restrictions have made migration more perilous and imposed even more fragility on migrants. The hurdles to obtain regular entry visas expose high numbers of migrants to the hazards of unsafe border crossings, the huge costs of people smuggling, and hostile working conditions due to irregular migration status. In developing countries, the levels of restriction to entry may be lower, yet the absence of proper migration policies entails equivalent effects of restrictive policies (de Wenden, 2013). The relative unrestrained crossing at the border is often followed by a steep path toward regularization. Irregular migration status results in precarious labor conditions, which may then lead to deteriorating health and more obstacles to socioeconomic inclusion.

The Recognition of Migrants’ Right to Health by the UN System

In the realm of international organizations dealing with health, there have been increasing efforts to encompass the knowledge and political action toward the protection of migrants and refugees’ health conditions. The World Health Organization (WHO), in particular, has acknowledged the impact of migration on health by successive resolutions and reports of the World Health Assembly and the WHO Secretariat,8 which endorsed the assumption that migrants and refugees face specific circumstances and obstacles to their physical and mental well-being at each phase of their displacement. Accordingly, these documents have recently culminated in the adoption of the latest Draft Global Action Plan “Promoting the Health of Refugees and Migrants (2019–2023),” in May 2019.

Among the plan priorities, one may highlight the urgency for the promotion of the health of refugees and migrants through short-term and long-term public health interventions; sensitive health policies and legal and social protection; the health and well-being of refugee and migrant women, children, and adolescents; health monitoring and health information systems; and the need to counter misperceptions about migrant and refugee health in destination countries. It may yet be too early to assess the resonance of the plan on the actual health conditions of migrants worldwide. Nevertheless, it provides the first global coordinated commitment specifically addressing the topic and setting out the roles of WHO, member states, and other international partners. As a typical soft law instrument, it presents no sanctions for noncompliance, and may still lack incentives to induce member states to implement it (Onarheim & Rached, 2020).

Along the same lines, the Pan-American Health Organization (PAHO), as the WHO regional extension in the Americas, has also conducted a series of discussions and issued documents putting forward guidelines to generate responsive health policies regarding migrants and refugees. In September 2016, the Directing Council of PAHO adopted Resolution CD55.R13 “Health of Migrants,” which urges its member states to provide equal access to quality health services, regardless of migratory status, enhance legal frameworks to address the specific health needs of migrants, and promote the coordination policies in the border areas between countries (PAHO, 2016). Yet again, the resolution is constrained by the member states’ contexts and priorities and does not provide for any sort of sanction on those not abiding by it.

The International Organization for Migration (IOM), as the main body composing the UN system dedicated to migration and its related issues, has introduced a specific framing of the health of migrants that takes on the concept of social determinants of health, as defined previously in the article. The IOM images found at Social Determinants of Migrant Health depict the complexity of those determinants concerning the health outcomes of migrants and refugees as a combination of personal traits and structural circumstances, all over the migration process in origin, transit, and destination sites. This approach has been guiding the projects in which the IOM engages itself and constitutes a tool to influence migration policies in the territories where the organization operates. In Latin America and the Caribbean, the IOM keeps two main regional offices based in Argentina and Costa Rica, as well as several subsidiary offices coordinating local initiatives in zones of interest to the organization (IOM, 2021).

Competing Approaches to Migration and Health: Securitization vs. Human Rights

There has been a lively academic debate around the concept of security over the last few decades and its pervasive link with political processes, which tend to widen the scope of security and legitimize extraordinary measures to fulfill their political agendas. Critical approaches in security studies point out the entanglement of migration and asylum with security matters, as a peculiar process by which political actors frame the arrival and presence of foreigners as an existential threat to the unity and identity of the host community.

Huysmans (2006) underlines the paradox of such a political move, which invokes the need to secure the social and political integrity of national communities by highlighting their insecurity in a hostile international environment, plagued with menacing external pressures. From this perspective, immigrants embody the dread of dissolution or irreversible transformation of local societies (Nunes, 2014), which therefore demands intervention from policymakers, usually in the form of physical or administrative barriers (border walls and fences, detention centers, burdensome visa requirements, etc.), besides latent racial conflicts within host societies.

The same imaginary of purity and protection against external threats surrounding the dread of disease and infection bolster the all-too-common link between migration and health, which often frames migrants as vectors of disease and the ultimate source of social unrest and decay. In the wake of the COVID-19 pandemic, there was no shortage of racialized blaming the Chinese management about the outbreak, as channeled in the rhetoric of former President Trump (Reny & Barreto, 2020).

The previous public health international emergencies of Ebola (2014) and the Zika-related syndrome (2016) also illustrate the securitization of health. The first involved the intense deployment of military forces in the affected regions in West Africa and led to explicit intervention by the UN Security Council to avoid the outbreak from irreversibly reaching the territory of the developed world (Burci, 2014; Ventura, 2016). The second, whose epicenter was Brazil and some neighboring countries of Latin America, implied the promotion of the “war on the mosquito” Aedes aegypti by the federal government, overlooking the underlying social inequities causing the disease to affect the most disenfranchised, namely low-income, non-White women and their babies (Ventura et al., 2020). Even nowadays, some Latin American and Caribbean countries impose travel restrictions to people living with HIV, among which are Cuba, the Dominican Republic, Paraguay, and Belize (UNAIDS, 2019).

According to other strands of the debate, the political use of security as a means to advance certain agendas need not bring about detrimental effects to human rights. Affiliates of the concept of security as a source of emancipation stand for the capacity to subvert ideas of security and health, often depicted as the foreclosing of imagined external threats, to mitigate the suffering of the most vulnerable social groups and foster their autonomy and well-being (Nunes, 2014). That conception of health and security lies closer to the perspective of human rights praised by some global health scholars and literature and is also endorsed by the international framework outlined in the section the “Recognition of Migrants’ Right to Health by the UN System.”

Accordingly, the human rights perspective connecting public health and the right to health of migrants is concerned with the state’s obligation to promote migrants’ rights without any sort of discrimination. It sustains that restricting their rights entails vulnerability and inequities related to health, whereas recognizing them promotes integration, avoids long-term social and health costs, and boosts economic development (Ventura & Yujra, 2019). By scrutinizing the migration process as a whole and the systematic limitations posed by places of origin, transit, and destination, this approach also encourages international cooperation between states in order to tackle the drawbacks in migrants’ health results.

The Advances and Shortcomings in Latin America and the Caribbean (National Legislation, Policies, International Cooperation)

Following global trends in international migration, most countries in the region are currently origin, transit, and destination points to migrant flows. South America, for instance, according to IOM data, hosts about 10 million immigrants and is the origin of another 17 million around the world. Up to 2019, 80% of the immigrants in the subcontinent were from other South American countries, although immigration from Africa and Asia has risen nearly 40% in 10 years. Immigration from Caribbean countries, particularly from Haiti and the Dominican Republic, has noticeably almost doubled from 2010 to 2019 (IOM, 2020b). These figures reflect the dynamic mobility patterns in Latin America, which pose challenges to the public policies dealing with newcomers, even in countries with a lasting migration background.

In South America, Brazil and Argentina have historically been two main destination poles to thousands of migrants in the region. Since the last quarter of the 20th century, both have attracted labor migration from neighboring countries, especially Bolivians, Paraguayans, and Peruvians, whose inflow corresponds mostly to the economic demand in urban contexts, the contrast in development performance, and education opportunities.

Bolivians, in particular, have become the second-largest immigrant group in both Brazil (Cavalcanti et al., 2019) and Argentina (Argentina, Ministry of Interior, n.d.). The Bolivian migration is often associated with exploitative working conditions in the garment industry production chains in metropolitan regions like Sao Paulo and Buenos Aires. Accordingly, public health demands and interventions aimed at this group underscore the impact of such socioeconomic circumstances: Injuries and respiratory diseases are the frequent result of long working shifts in crammed sweatshops, where many migrants live and work simultaneously (Goldberg & Silveira, 2013).

Since 2010, Haitians have represented another major migration flow in Latin America, mainly due to the deterioration of socioeconomic conditions after the earthquake that affected the country that year. The great majority of international migrants in the neighboring Dominican Republic are Haitians, at nearly half a million people (IOM, 2019). They have also become the most important long-term migrant foreign group in Brazil from 2010 to 2018, at over 100,000 (Cavalcanti et al., 2019), and most have attained regular status based on humanitarian principles. Driven mostly by labor opportunities, the remittances from Haitians working abroad accounts for a third of the Haitian GDP (IOM, 2019). Despite the protective legislation in terms of access to residence permits, economic data from Brazilian authorities demonstrate they were among the lowest income foreign group in the country in 2018 (Cavalcanti et al., 2019). Research also suggests that Haitian migrants are often absorbed by the Brazilian labor market in low-paid positions, under rather precarious or hazardous conditions, particularly in the construction and meat-processing industries, which may result in occupational health harms (Costa Leão et al., 2018).

Along economic constraints, another major force driving migration in the region is political instability and violence caused by internal conflicts (Cerrutti & Parrado, 2015), as in the case of Colombia and Venezuela. According to the UNHCR, nearly 8 million Colombians have been victims of forced internal displacement until 2019 (UNHCR, n.d.), due to the armed conflict between the FARC guerrilla group and the government, although the demobilization of armed groups and the peace agreement signed in 2016 have mitigated forced migration. While being the origin of thousands of refugees headed for Venezuela since the 1970s, the country deals at present with the reverse trend of the massive Venezuelan incoming population, estimated at 1.6 million, out of 4.6 million in total (OIM, 2020b).

The current flow of Venezuelans throughout the region and beyond has been pushed by the crumbling economic performance and the coarsening political regime under Nicolás Maduro, which has isolated the country in the international sphere. The ongoing crisis has severely affected the Venezuelan healthcare sector, which has endured chronic shortages of medical supplies and equipment (Lancet, 2018), besides the departure of some 30,000 Venezuelan health professionals in the 2010s (Standley et al., 2020). The massive outflow from Venezuela magnifies the humanitarian crisis, recognized by several neighboring countries, which have provided rather inadequate responses to the incoming Venezuelan citizens, particularly after the onset of the COVID-19 pandemic, as discussed further. The successive and manifold migration flows in Latin America and the Caribbean demonstrates the complexity of migratory networks and dynamics in the region, to which the political and legal provisions considerably vary between and within countries.

Some countries have nevertheless been able to enact milestone legislation acknowledging migrants and refugees’ human rights, which spilled over to the main regional migration governance instrument, the Mercosur Residence Agreement (RA), in force since 2009. Argentina, in particular, spearheaded such a trend, by passing its National Migration Law n. 25,871 in 2004, which among other provisions paradigmatically recognized the “inalienable right to migrate” (art. 4) and access to healthcare regardless of migration status (art. 8). The country also played a major role in the negotiations of the Mercosur RA and pushed for an arrangement that allowed for the permanent regularization of thousands of citizens from the RA’s member states living in any of their territories (Braz, 2018). The RA nowadays encompasses the original four founding Mercosur member states (Argentina, Brazil, Paraguay, and Uruguay), the bloc’s associate members Bolivia and Chile, besides Peru, Ecuador, and Colombia.

The Argentinian and the Brazilian experience of successive migration amnesties to undocumented migrants in the second half of 20th century proved inadequate to provide regular migration status to the ongoing flows stemming mostly from neighboring countries in South America. The mismatch compelled the representatives of the country in Mercosur to encourage an agreement to dissolve the gap between the regulation and the actual incoming flows (Braz, 2018). Internally, the National Migration Law in 2004 shifted the securitarian paradigm of the previous legislation enacted during the dictatorial regime ruling the country between 1976 and 1983. Brazil, Ecuador, and Peru followed suit and passed their latest migration legislation in 2017, which incorporated a much broader range of fundamental rights of migrants, including to healthcare, and consolidated the orientation toward a human rights approach in the region (García & Nejamkis, 2018).

Despite the legal recognition of migrants’ and refugees’ rights, these groups may lack appropriate living standards, reflecting the overall lagging social policies in the region. In terms of healthcare, the extension and quality of public health services function under diverse circumstances, according to each country’s capacity to implement policy and provide proper care, besides the barriers the migrant population commonly face at the points of care. Among such barriers, the literature highlights the linguistic and cultural gaps between citizens and services, for which health systems must adapt and respond adequately (IOM, WHO, & UNHCHR, 2013; Ventura & Yujra, 2019). Even public universal health systems, such as the Brazilian Unified Health System (SUS), lack adapted care protocols for non-nationals and systematic information on the migrant population entitled to access care, although there have been a few initiatives to narrow that gap in high-demand areas, such as hiring of migrants by healthcare institutions in the city of Sao Paulo (Steffens & Martins, 2016; Ventura & Yujra, 2019).

The Brazilian government has recently introduced austerity policies, which represent a major structural threat to the public healthcare system and jeopardize its very sustainability and capacity to provide care to the whole population, including migrants and refugees. The chronic underfunding of SUS may soon reach unprecedented levels, due to a constitutional amendment passed in 2016, which set a cap on public healthcare expenses and resulted in a US$4.3 billion loss between 2018 and 2020 (Brazil, 2020). The cap is likely to further cripple the system and gravely affect the health standards of millions of people depending on the services, particularly the most vulnerable, even more so in the aftermath of the global COVID-19 pandemic.

The COVID-19 Pandemic: Pitfalls and Opportunities

The COVID-19 pandemic has put all healthcare systems to proof in the region, which has so far accounted for over a quarter of confirmed cases and one third of the related deaths. The pandemic responses have varied widely between countries, ranging from populist denialism in countries like Brazil and Mexico to rigid quarantine measures in Argentina and Colombia (Taylor, 2020). Yet with spiraling infection rates and relatively high mortality, the region may be facing a consequential humanitarian crisis, not only due to COVID-19 itself but also to the syndemic characteristics of the disease, that is, the combination of the viral infection with noncommunicable diseases related to the rampant social inequality in the region (Lancet, 2020).

One of the main elements contributing to the magnitude of such a crisis is the continuing displacement of people within and across borders in the pandemic context, in particular that of Venezuelan migrants, which has not found proper political responses from neighboring countries. Colombia and Brazil have both imposed border restrictions on incoming Venezuelans since the beginning of the outbreak, which even motivated thousands of them to try their return to their country of origin and face harsh treatment from the Maduro regime (Standley et al., 2020).

In Brazil, in particular, the federal government has issued a series of decrees ruling over the transit of foreigners and border controls, which specifically discriminate against Venezuelans by banning their entry into the country, even when they present a residence permit, and allowing summary deportations (Standley et al., 2020). Such measures violate Brazilian legislation and international treaties to which the country is a party (Rosa et al., 2020) and signals the strategy to use the exceptional circumstance of the pandemic to jeopardize protective migration law.

Meanwhile, for those migrants already residing in the country, there has been some support during the pandemic in the form of the financial aid approved by Congress by March 2020, which allowed for a 600-real monthly income (about US$100), over a period of 5 months and an additional 3-month grant of half that amount. According to official data, nearly 150,000 regular migrant residents have been able to benefit from the grant, stemming mostly from neighboring countries, such as Venezuela, Haiti, Bolivia, Colombia, and Paraguay.

The access to emergency financial aid, however, contrasts with the general lack of political coordination and strategic measures to tackle the pandemic, whose toll in Brazil has been the second-highest worldwide. With regards to migrants and refugees, one can only assume that the burden has been particularly heavy for those in low-income areas, as the health authorities have thus far provided no data on that population at any level of government, which implies there are no specific plans to protect their health.

Borders have also been closed due to the COVID-19 pandemic in Colombia, where over 1,700,000 Venezuelans are estimated to reside (Colombia, 2020). A minor portion of that population, roughly 100,000, left the country toward Venezuela and are currently making their way back into Colombia, despite the border restrictions. In fact, the considerable Venezuelan flow to Colombia has been quite heterogeneous, composed by Colombian returnees, regular and irregular migrants, and pendular border migrants (World Bank Group, 2018). The Colombian healthcare system, which is not based on universal access, tends to exclude irregular migrants from full coverage (Asociación Profamilia & USAID, 2020). The closing of borders adds to the challenging context and is likely to undermine the efforts to tackle that exclusion.

Argentina, as one of the main destination countries in the region, has also imposed border restrictions and opted for a severe lockdown for most of 2020, which inevitably affected the livelihood of many of the migrants in the country, particularly those engaged in informal jobs. A preliminary study published by the IOM highlighted that over two thirds of its surveyed migrants, mostly newcomers from Venezuela, were unemployed and faced serious food insecurity in the first few months of the pandemic, while being the least likely to have access to governmental financial aid (IOM, 2020a). The country extended the national lockdown until November 2020 and managed to keep the disease under relative control for months, yet IT has seen rising numbers of victims toward the end of the quarantine, amid hopes for a massive vaccination campaign in 2021.

On the one hand, the Mexican government, for its turn, managed to collect some important data on the direct impact of the pandemic in its first few months on migrant groups and followed up on cases of contagion and decease of foreign residents.9 On the other hand, the country has fallen short of implementing adequate policies to protect the rights of migrants and asylum seekers in the context of the pandemic. According to a comprehensive report by the Mexican Commission for the Defense and Promotion of Human Rights (2020), the country has failed to guarantee the protection of migrants in the temporary detention centers under the authority of the National Migration Institute, which is in charge of enforcing the national migration policy. The shortage of proper sanitary conditions has led to violent riots and demonstrations.

Moreover, the report underscores the dire consequences of the agreements between Mexico and the United States related to the forceful control of migration flows toward the latter. The countries share one of the most lethal migratory routes in the world, whose precariousness has been exacerbated by the so-called Migrant Protection Protocols, also known as the “Remain in Mexico” program. Such agreement allows for the summary return of non-Mexican asylum seekers by U.S. border authorities to endangered locations in Mexico as their asylum claims are adjudicated without legal assistance in U.S. courts. In practice, the policy has resulted in dozens of thousands of returns, added to over a 100,000 summary deportations estimated to have taken place until mid-2020 by the United States (Mexican Commission for the Defense and Promotion of Human Rights, 2020), which made Mexico the receiving end of a distorted system of violation of the international law of refugees.

Such a distortion, before the COVID-19 pandemic, has been mostly affecting the thousands of people stemming from the north of Central America (El Salvador, Honduras, and Guatemala), whose flows toward North America, particularly the United States, through Mexico have intensified despite mounting controls. According to Faret et al. (2021), the migratory system connecting Central and North America have been a myriad of plans and projects, such as the U.S. “Plan of the Alliance for Prosperity in the Northern Triangle” or Mexico’s “Southern Border Program,” reflecting the externalization of U.S. borders, which endorses the militarized containment of flows in detriment to migrants’ and asylum seekers’ human rights. The securitarian approach to the continuous flow in this migration route has led to even more hazardous displacement conditions and systematic abuses against migrants by organized gangs, officials, and even local populations.

Simultaneously, the so-called caravans of Central American migrants crossing the Mexican territory towards the United States were the corollary of social networks of migrants trying to circumvent such hurdles to their movement and attain visibility to their claims (Faret et al., 2021; Gandini, 2020); the caravans were composed of mainly displaced families fleeing violence, misery, and impunity of political regimens (Varela, 2020). A relevant component of such flows is the increasing migration of women and unaccompanied girls, due to different types of violence, including sexual harassment, coercion, and extorsion, which implies the need for a gender perspective in migration policy and scholarship (Camargo Martínez, 2014; Eguiluz, 2021).

The unilateral closing of borders, the hardened policies put in place to detain migration flows, and individual responses by national governments to tackle the effects of the COVID-19 pandemic are all expressions of an ongoing process of decline in international cooperation in the health field in Latin America. The rise of conservative and far-right governments in the region led to the emptying of initiatives that until recently forged important partnerships and harnessed beneficial health policies. An outstanding example of that cooperation was the Union of South American Nations (UNASUR) and its South American Institute of Government in Health (ISAGS), which represented the most relevant integration experience in the field of public health in South America by fostering the interchange of health policies and expertise among policymakers and practitioners from UNASUR member states and enhancing the capacities of their health authorities to manage public health systems (Riggirozzi, 2014).

Brazil, as a major player in the health field, fulfilled a crucial role to set up the organization and deploy integration mechanisms to diffuse its health policies among the UNASUR members. The demise of UNASUR also coincided with the emergence of the far-right Bolsonaro administration, which enacted a disruptive role in the multilateral relations of the country and reoriented its foreign policy toward an automatic and subservient tie with then President Trump. The conservative alliance between the far-right leaders has led to medical populist performances, using alternative knowledge claims to cast doubt on the credibility of experts (Casarões & Magalhães, 2020). Internally, the Brazilian response to the COVID-19 pandemic coupled populism (Ventura & Martins, 2020) and the strategic neglect of public capacities (Ortega & Orsini, 2020), which accounts for the appalling mortality rates and the absence of regional leadership the country used to exert.

An effective multilateral cooperation in the region should be able to promote mutual consultations and assistance to tackle the pandemic and mitigate its effects on the health of the whole population, including migrants and refugees. Buss and Tobar (2020) suggest a series of measures that might fill the void left by the end of UNASUR, despite the fragmented strategies the countries in the region have adopted so far. Among such steps, they cite data exchanges and the follow-up of the pandemic in each country; the creation of a regional network of laboratories for the diagnosis of COVID-19 and other viruses; the mobilization of national institutes of public health and schools of public health aiming to share timely research, human resources training, technical assistance, and the adoption of mechanisms for joint negotiation and purchase of strategic inputs. However, the outlook for cooperation is rather bleak, even more so for migrant populations. As the perspective of massive vaccination for COVID-19 unfolds, multiple governments of the region signal how they give the protection of migrants low priority, such as in Colombia, where the president has claimed nearly a million of irregular Venezuelan migrants are not entitled to the vaccines (Bluradio, 2020).

Conclusions

Contemporary migration in Latin America and the Caribbean reflects the manifold dynamics of human mobility in a world of relentless exchange of flows, despite all restrictions imposed by the nationalist rationale. The region has become a transit, origin, and destination zone to diverse streams of populations, bolstered by economic and political turmoil, as well as incremental cooperative mechanisms facilitating the circulation of people, such as the Mercosur RA. Yet with regard to the fulfillment of migrants’ rights and, in particular, their right to health, the prospects are still grim, insofar as they correspond to the general shortcomings impairing the region’s socioeconomic development.

As previously indicated, the region has been able to set up an array of institutions and count on the support of an international framework to foment the protection of migrant populations, such as the Inter-American Human Rights System and the Declaration of Cartagena on Refugees. With respect to health, the multilateral cooperation in the realm of the Pan-American Health Organization (PAHO) and the International Organization for Migration (IOM) has played a fundamental role. The Union of South American Nations (UNASUR) represented a step further in the direction of cooperation in health, sponsored by the Brazilian leadership in the region, yet could not survive the backlash on multilateralism following the rise of conservative governments.

The COVID-19 pandemic is likely to have far-reaching consequences and aggravate the dire circumstances of people in displacement. On the one hand, it has caused governments in Latin America to handle the crisis in a fragmented and unilateral fashion, ignoring opportunities to cooperate and shield the livelihoods of the most vulnerable. On the other hand, it has served as a pretext to sharpen the restrictions to cross-border movement and, ultimately, undermine the obligation to protect the dignity of migrants, as the cases of Venezuela and the U.S.-Mexico border illustrate. The association between foreigners and disease accompanies the history of epidemics and is maintained to potentially induce or justify human rights violations (Ventura, 2016). Therefore, one of the major risks the pandemic may pose to migrants and refugees is the diffusion of the notion that these groups are vectors of disease and further hinder their access to health systems, regularization, and other social rights, including proper treatment of COVID-19.

The International Health Regulations (IHR), adopted in the realm of the WHO and in force in 196 states parties, is the most relevant international health norm and stipulates a global framework to prevent, protect against, control, and provide a public health response to the international spread of disease in ways commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade (art. 2). Article 32 assures that in implementing health measures under the regulations, states parties shall treat travelers with respect for their dignity, human rights, and fundamental freedoms, as well as minimize any discomfort or distress associated with such measures (WHO, 2008b). Nonetheless, during the COVID-19 pandemic, several states have ignored their obligations in the light of the IHR (Habibi et al., 2020) and made migrants and refugees scapegoats of the pandemic.

Inspired by these shared principles and understandings of a sensible response in times of health emergencies, countries in Latin America and the Caribbean should grasp this consequential event to restore and strengthen cooperation mechanisms aiming to protect the health of all their citizens. As previously stated, such efforts go hand in hand with the consolidation of their institutions and, particularly, the development of robust and inclusionary public health systems. The worldwide responses to the COVID-19 pandemic highlight the preeminent role state-funded institutions must fulfill to avoid the diffuse effects of the disease. That safeguard cannot be ascribed only to national populations in an ever-more mobile world.

Acknowledgments

UNAM, Programa de Becas Posdoctorales en la UNAM, Coordinación de Humanidades, Instituto de Investigaciones Económicas, asesorada por el Dr. Lorenzo Alejandro Méndez Rodríguez

References

Notes

  • 1. According to the WHO, the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life, including economic policies and systems, development agendas, social norms, social policies and political systems.

  • 2. UNHCR, Convention and Protocol Relating to the Status of Refugees.

  • 3. UN Treaty Collection, Status of Treaties.

  • 4. UNHCR, Latin America Funding Update.

  • 5. UN Treaty Collection, Status of Treaties.

  • 6. United Nations A/RES/73/195, 73rd sess. Resolution adopted by the General Assembly on December 19, 2018.

  • 7. United Nations, Sustainable Development Goals.

  • 8. The World Health Assembly is WHO’s main decisive body, which convenes representatives from state members in charge of public health issues. Among its functions, the World Health Assembly rules on the policies and agreements adopted by WHO and periodically elects its general director.

  • 9. As of November 2020, the Mexican Ministry of Health had reported 732 confirmed cases and 40 COVID-19-related deaths among foreign residents.