As of 2017, over 258 million people lived outside of their home country, an increase of almost 50 percent relative to 2000 (UN DESA 2017). Many of these people, including countless women and children, were forced from their homes and families by violence and natural disasters. Many live and work under precarious and exploitative conditions, often facing the specter of deportation. Others are victims of human trafficking, subject to violence and exploitation.
As migration flows continue to mount, policies protecting vulnerable migrants’ rights, particularly their right to basic health care and work, are critical to safeguard their dignity and facilitate their successful integration into host societies. Policies enhancing migrants’ access to health care and promoting migrant entrepreneurship, in particular, strengthen vulnerable migrants’ self-sufficiency and enable them to lead fulfilling lives. While governments and international organizations increasingly recognize the need for such policies, migrants’ access to health care remains limited across much of the globe. Indeed, migrants’ foreign citizenship or lack of legal status often impedes such access. Even when health care is available, providers often lack the linguistic and cultural skills necessary to treat migrants effectively.
Migrants also frequently face labor market difficulties. Jobs are often scarce, and foreign-earned skills credentials often go unrecognized in host states. Some employers prefer to hire natives, particularly when migrants do not speak their host societies’ languages. In such contexts, entrepreneurship constitutes a promising way for migrants to support themselves and their families. Those wishing to start businesses, however, are often hampered by a lack of startup capital or knowledge of local business law.
This paper highlights the potential of faith-based organizations to improve the health and work outcomes of vulnerable migrants. Faith-based organizations are defined as agencies founded on the principles of faith and religion. They include religious congregations (e.g., churches, mosques, synagogues, or temples), programs or projects sponsored by a religious congregation, and nonprofit organizations founded by religious congregations or individuals motivated by religion (Ebaugh, Pipes, Chafetz, and Daniels 2003). Such organizations possess valuable networks and resources that can support migrants’ access to health care and productive employment even under challenging circumstances. They often play a vital role in strengthening the livelihoods of the world’s most vulnerable migrants, including refugees, asylum seekers, and migrants without legal status.
This paper will proceed in two parts. Part I will describe obstacles to the provision of adequate health care to migrant populations. It describes how faith-based organizations expand health care to underserved populations and play a vital role in building trust between health care providers and migrant communities. Part II describes obstacles to migrant employment and explains how faith-based organizations are promoting migrant entrepreneurship through training, referrals, and targeted micro-loans, among other services. The paper concludes with a brief discussion of how the international community might support faith-based organizations’ efforts in these areas. In particular, the Global Compact on Migration should recognize faith-based organizations’ unique resources and credibility among vulnerable migrant populations. It should also emphasize the potential for productive cooperation between international organizations and faith-based organizations in the areas of migrant health care and entrepreneurship.
I. Migrant Health: Challenges and Responses
Access to health care is vital to migrants’ ability to lead fulfilling lives. Such access is a fundamental right enshrined in international law. Article 25 of the 1948 Universal Declaration of Human Rights emphasizes that “[e]veryone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.” Likewise, Article 2.2 of the International Covenant on Economic, Social, and Cultural Rights stipulates that all individuals must have access to health care. States are expressly prohibited from discriminating against non-nationals on the grounds of “race, colour, sex, religion, language, religion, political or other opinion, national or social origin, birth or other status. Per international law, then, governments are obligated to provide migrants with adequate health services, support the prevention, treatment, and control of diseases, and facilitate health education. This includes providing affordable health insurance, treatment, and essential medications. States are responsible for ensuring that health care is provided equitably to all individuals within their borders, regardless of their immigration status.
a. Migrant Health Challenges
Despite these international legal obligations, states frequently bar noncitizens from receiving health care, particularly when they are unauthorized or awaiting adjudication of their asylum claims. Some countries provide such migrants access only to emergency care, while others provide only rudimentary health services at detention centers. As of 2016, unauthorized migrants had immediate access to universal health care only in Thailand, and even there some hospitals refused to provide them with insurance (Yan 2016)).
Barring migrants from health care constitutes a violation of their rights under international law. Migrants’ exclusion from health care is based on the misperception that treating noncitizens would place a heavy burden on national healthcare systems. In general, however, migrants tend to be younger and in better health than native-born populations (IOM 2013). Barriers to health care in receiving countries, however, can put their health at risk. Health problems left untreated can worsen over time, and limiting migrants’ access to health care can ultimately lead to longer hospital stays, more acute health crises, and higher mortality rates (Ruiz-Casares et al. 2010).
Migrants in detention may face particularly acute health risks. Doctors and nurses are not always available in detention facilities, and those available do not always have the authority, equipment, or medicine to properly treat patients. In the United States, a lack of adequate medical staffing at many detention facilities has created significant treatment delays and backlogs, contributing to the deaths of numerous detainees (Priest and Goldstein 2008; Yu 2018). The availability of specialized health services is often limited. Pregnant detainees, in particular, often lack adequate care (IOM 2013). Detainees also frequently lack access to counseling and psychiatric care. Indeed, a majority of Immigration and Customs Enforcement (ICE) detention centers lack mental health providers (Seattle University School of Law International Human Rights Clinic and OneAmerica 2008; AIC 2018).
Detention centers are also frequently overcrowded and possess poor sanitation. This can increase the prevalence of diseases, particularly infectious and psychiatric disorders (Semenza et al. 2016). A study of over 2,200 unauthorized immigrants in Malta found that a majority of health problems experienced by detained migrants resulted from overcrowding, poor hygiene, and poor nutrition at detention centers (Padovese 2016).
Migrants’ exclusion from health care not only increases their vulnerability, but also exposes their host societies to greater financial costs and public health risks. Indeed, medical conditions left untreated may become more expensive and difficult to treat over time. Waiting for treatment may ultimately lead to longer hospital stays, placing a burden on healthcare systems. Finally, contagious conditions may spread to migrants’ communities and to native populations. Anti-retroviral treatments, for example, are not available to irregular migrants in many European countries, heightening the risks of HIV transmission (European Center for Disease Prevention and Control 2016).
Even when migrants have legal access to health care, it is difficult for them to receive adequate treatment. For one, they often have health needs that differ from those of native-born populations, complicating their treatment. For example, many suffer from trauma due to exposure to violence or loss prior to migration. Those displaced due to conflict or natural disasters may be at greater risk of adverse outcomes (European Center for Disease Prevention and Control 2016). They have often experienced traumatic events en route to their host countries or upon arrival (ibid.). Those who left family members behind or who lack legal status are particularly prone to psychological stress, which can exacerbate physical ailments (Semenza et al. 2016). A 2017 study of young immigrants in the United States found that refugee youth are exposed to more violence than other immigrants on average, and consequently experience higher rates of dissociative symptoms, traumatic grief, somatization, and phobic disorders (Betancourt et al. 2017).
Migrants also arrive from regions with different epidemiological and health profiles than their host countries, or have genetic predispositions to conditions that are uncommon in those countries. Tuberculosis, iron deficiencies, micronutrient deficiencies, and dental diseases are particularly common (Betancourt et al. 2017). HIV and syphilis are also very common. They may also lack formal medical records or histories, complicating health providers’ efforts to provide accurate diagnoses and effective prescriptions (Jensen et al 2011).
Migrants also frequently work in environments where they are at risk of work-related injuries. Studies suggest that they are at higher risk of workplace-related accidents than natives (Eurofound 2007; Sri Lanka Bureau of Foreign Employment 2009). Many work in hazardous sectors such as mining, construction, and agriculture. A survey of nearly 30,000 workers in 31 European countries revealed that migrants were more likely than native-born workers to be exposed to high temperatures, loud noises, and strong vibrations, and to stand for long periods of time (Ronda Perez et al. 2012). They often work long hours and sometimes develop fatigue, putting them at risk of occupational accidents. They might also be exposed to pesticides and other chemicals. Furthermore, migrants might be reluctant to report dangerous working conditions or exploitative practices, particularly if they lack legal status and fear deportation. In some countries, they are not allowed to form or join trade unions to advocate for better working conditions (ibid.). Linguistic limitations can also impede their understanding of safety procedures and limit their ability to file complaints, placing them at further risk.
Female migrants are also at high risk of sexual exploitation in the workplace, particularly if they lack status or earn their living as domestic workers. They might be reluctant to report rape or abuse by their employers for fear that they will be deported or lose their livelihood. Such individuals might be at a particularly high risk of sexually transmitted diseases.
Migrants are also often unaware of services available to them, particularly when little information about health care is available in their own languages. In particular, they are frequently unaware of options for pre- and post-natal care. In Western Europe, this has contributed to higher rates of mortality and morbidity among migrant women than among the native-born (Ronda Perez et al. 2012).
Unauthorized migrants are particularly unlikely to seek care. They often fear that seeking health care will place them or their families at risk for deportation. Correspondingly, a 2007 study of Mexican immigrants in California found that unauthorized immigrants were 27 percent less likely than their authorized counterparts to have visited a doctor in the previous year (Bustamante 2012).
In many countries, unauthorized migrants lack access to health insurance and must pay for their health care out of pocket. Many, thus, delay treatment when they lack financial means. They may also be unable or unwilling to provide proof of residency or other documentation that is necessary for referrals and prescriptions in some countries. Irregular status often also limits migrant children’s access to basic health care. In some countries, parents must be documented in order to obtain birth certificates for their children and enroll them in national health care systems.
When unauthorized migrants receive health care, it is often inadequate. Providers often do not know how to process migrants outside of national health insurance schemes. Some providers may fear the legal ramifications of providing services (Jensen 2011). In some cases, doctors may be unwilling to write referrals or prescriptions for uninsured immigrants since such services may create financial hardships for migrants and even put them at risk of deportation if they must be enrolled in national health registries (ibid.).
Migrants also have logistical difficulties accessing health care. They regularly lack transportation to health clinics or hospitals. In a study of migrants’ health in rural eastern North Carolina, for example, 80 percent of respondents considered transportation as a major obstacle to receiving health care (Weathers et al. 2004). They also frequently have inflexible work schedules that impede their ability to request time off for health care. Finally, they may live in remote or rural areas with few providers.
Healthcare workers often have limited to no knowledge of immigrant languages and cultures. Mistranslation can lead to misinterpretation of symptoms, which can result in postponed care, clinical errors, or even death. Furthermore, language barriers can limit medical professionals’ ability to explain the side effects of treatments and obtain proper consent. They can also limit providers’ ability to provide psychological support to immigrants and can impede the development of provider-patient trust. Language barriers can be a particularly severe impediment to treating HIV-positive populations, who may be reluctant to seek treatment from fear that their status will be disclosed (European Center for Disease Prevention and Control 2016).
Miscommunication can also undermine migrants’ trust in healthcare providers and willingness to take medications and undergo medical procedures. Many cultures view health care as spiritual and holistic as well as physical (Salant and Lauderdale 2003). Employing traditional healers, combining traditional medicine with modern treatments, or incorporating spiritual or cultural elements into medicine can build improve migrant health outcomes (Georgetown University Child Development Center 2001). Specifically, such practices could improve the effectiveness of health education, build trust between patients and providers, and encourage migrants to follow through with medical advice.
b. Faith-Based Organizations and Migrant Health Outcomes
Globally, faith-based organizations of many denominations play a critical and unique role in extending health services to underserved migrant populations. Empirical evidence suggests that faith-based programs can improve health outcomes among vulnerable populations (DeHaven et al. 2004). This section highlights several key ways that faith-based organizations strengthen migrants’ health care. First, faith-based organizations are trusted and respected by migrants and government actors alike, granting them access to vulnerable populations that many organizations lack. Second, they often possess devoted networks of volunteers that enable them to reach underserved populations. Extensive volunteer networks and knowledge of local communities also facilitate the delivery of linguistically and culturally appropriate health services. Finally, they are effective at sensitizing authorities and service providers to the needs of migrants.
Faith-based organizations are often widely trusted and respected by governmental actors and migrants alike. This trust and respect grants them access to vulnerable populations that other organizations lack, including from irregular migrants and asylum seekers. In Nicaragua, for example, the Council of Protestant Churches and the Managua mosque have direct access to immigrant detention centers (UNHCR 2014). The United Nations High Commissioner for Refugees (UNHCR) partnered with these organizations and Caritas to improve migrants’ reception conditions and provide support to asylum seekers. In Lebanon, Dar-el-Fatwa, an Islamic organization, assists UNHCR’s efforts to provide health care to Syrian refugees, including individuals residing in areas to which the United Nations lacks access. Dar-el-Fatwa has helped the UNHCR gain refugees’ trust and expanded its reach through a large network of volunteers (ibid.). The International Catholic Migration Commission facilitated the pre- and post-natal care of 2,000 pregnant Syrian women in Jordan and provided psychological support to thousands of refugees in Jordan and Greece, including many children. In Brazil, faith-based organizations such as Caritas work in remote areas and border regions to provide emergency assistance and referrals for asylum claimants and to sensitize service providers to migrants’ needs (ibid.). In Haiti, the Missionaries of Saint Charles, Scalabrinians, established a healthcare and dental clinic that provides health and dental services for more than 350 people a day, most of whom were displaced from the 2010 earthquake. Similarly, the Scalabrinians established a health and dental clinic in Delray Beach, Florida, providing services for migrants. Catholic diocesan health committees and bishops’ health commissions across the globe are also working to improve migrants’ health care outcomes.
Religious organizations can also be effective at addressing sensitive public health topics. In Iran, Muslim leaders partnered with the UNHCR to endorse and disseminate materials on gender-based violence to Afghan refugees. Muslim leaders added legitimacy to efforts to help women overcome social stigma and seek support. Similarly, in Ethiopia, faith leaders worked with the UNHCR to de-link female genital mutilation from Islamic teaching (UNHCR 2014).
Second, faith-based organizations often have access to volunteer networks that can facilitate the provision of health care to underserved migrant communities. Many such networks have trained doctors and nurses. These networks enable faith-based organizations to provide time-consuming or resource-intensive services beyond the scope of most health providers. Volunteers, for example, provide transport to clinics or hospitals or home health care services. These services bring health resources closer to patients and can be vital in rural regions with few doctors or clinics. Volunteers also can provide health care on evenings and weekends, facilitating access for migrants who work long shifts (Georgetown University Child Development Center 2001). Some also provide childcare services, giving migrants more flexibility to seek health care. In addition to volunteer support, faith-based organizations also frequently provide venues to disseminate health-related information. They host health seminars and talks and even organize basic health screenings (ibid.).
Faith-based organizations often possess strong knowledge of and ties to immigrant communities that facilitate the provision of culturally and linguistically sensitive care. They often serve as “cultural brokers” between immigrant communities and healthcare providers. Cultural and religious values often shape migrants’ responses to health education and interventions. When medical advice is presented from a host-country viewpoint, it may lack relevance to migrants’ cultural and religious contexts (Georgetown University Child Development Center 2001). Some recommendations may even contradict cultural and religious beliefs or practices.
Many migrants rely on their social networks and communities for information about health care. In close-knit communities, migrants place greater weight on the attitudes and opinions of community and faith leaders than of host-country doctors and nurses (Georgetown University Child Development Center 2001). Faith-based communities can tap into the credibility of faith leaders to provide health information and encourage healthy behaviors. They also partner with healthcare providers to enhance the effectiveness of health interventions. The ARK in Chicago, Illinois, for example, partners with Mount Sinai Hospital to help Russian- and Yiddish-speaking immigrants without insurance. Many of ARK’s volunteers are Russian and Yiddish speakers familiar with patients’ cultural and religious needs (ibid.). ARK provides its patients in-home care as well as eye and dental examinations.
In many cultures, spiritual counseling and traditional medicine are critical components of the healing process. Without these elements, migrants’ trust in health care may be limited. Faith-based organizations can tap into their networks to provide patients with traditional healing and spiritual support. The ACCESS Community Center in Dearborn, Michigan, for example, partners with the Oakwood Healthcare System to provide Islamic pastoral support and halal meals for Arabic-speaking immigrants. Furthermore, it provides Arabic-language health education materials incorporating Muslim religious principles (Georgetown University Child Development Center 2001).
Ultimately, such services can build trust between health care providers and immigrant communities. Increased trust can strengthen migrants’ compliance with medical advice and promote healthy behaviors. It can also build rapport between immigrant communities and health providers, increasingly the likelihood that migrants will consistently follow up in regard to their care.
Faith-based organizations are particularly critical in providing health care to undocumented migrants. Such migrants are often reluctant to seek health care out of fear of deportation (Nguyen and Gill 2016). Migrants may be more likely to seek health care when providers are recommended by trusted faith community leaders because they trust that their religious leaders would not lead them into harm’s way (Coddou 2017). In the United States, for example, partnerships between churches and federally qualified health centers have been shown to facilitate irregular Mexican migrants’ access to medical and dental care (López-Cevallos, Lee, and Donlan 2013).
Faith-based organizations also play a critical role in raising community awareness of migrants’ healthcare needs. They often lobby government authorities, for example, on behalf of migrant communities. In April 2018, for example, nearly 250 faith leaders wrote a letter to ICE condemning the detention of pregnant immigrant women. Through such actions, faith-based organizations can sensitize authorities to the needs and concerns of migrant communities.
In conclusion, faith-based organizations improve immigrants’ access to health care and facilitate the provision of culturally and linguistically appropriate services. Faith-based organizations’ credibility and volunteer networks allow them to build trust between immigrant communities and health providers, supporting positive health outcomes.
The International Covenant on Economic and Social Rights also stipulates that all individuals have the right to productive employment and satisfactory working conditions. Productive work helps migrants achieve economic self-sufficiency and promotes their integration into their host societies. In practice, however, many migrants have limited opportunities for employment. Many reside in regions with tight labor markets. They thus face steep employment competition with natives who speak local languages and possess strong social networks. Some migrants’ job prospects are limited by a lack of fluency in host languages (Marchand and Siegel 2015). Many also lack formal work authorization, limiting their employment options. Others lack proof of education or training from their homelands, and what formal credentials they possess may not be recognized by host societies. Finally, they frequently face discrimination on the basis of their legal status or ethnic or religious background (Zhou 2004). These obstacles can limit migrants’ prospects for gainful employment.
In light of these obstacles, entrepreneurship constitutes an important vehicle to improve migrants’ socioeconomic mobility (Zhou 2004; Constant, Shachmurove, and Zimmermann 2007; Irastorza 2010). Opening small businesses helps immigrants support themselves and their families. Entrepreneurship also creates jobs for other migrants and can positively impact local economic growth (Hosler 1996; Rath and Kloosterman 2000). Migrant-owned businesses also provide their communities with familiar food and clothing, uniting communities and fostering a sense of normality even under difficult conditions (Marchand and Siegel 2015).
Despite these benefits, prospective migrant entrepreneurs face many barriers. In particular, it can be difficult for them to acquire the capital necessary to start a business. Migrants often possess few savings, particularly if they fled their homelands due to violence or natural disasters (Evans and Jovanovic 1989; Evans and Leighton 1989). Banks are also often reluctant to provide potential migrant entrepreneurs with credit (OECD 2001). Migrants often have limited or non-existent credit histories in their host countries, making it difficult for them to obtain loans (Bruder, Neuberger, Räthke‐Döppner 2011; Desiderio 2014). They are also less likely to possess collateral than natives (Desiderio). Banks might also be unwilling to lend to migrants on short-term visas or without legal permanent residency (ibid.). Finally, migrants are often profiled on the basis of their immigration status or ethnicity or race (Blanchflower, Levine, and Zimmermann 2003). Those who succeed in securing loans may pay higher interest rates than native-born entrepreneurs (Albareto and Mistrulli 2010).
Prospective migrant entrepreneurs also face significant administrative challenges. They are frequently unfamiliar with host-country taxation rules as well as labor, social security, and safety regulations. Furthermore, language barriers and limited social networks can make it difficult for migrants to navigate bureaucratic regulations and procedures (Desiderio 2014).
Across the globe, faith-based organizations of many denominations are active in promoting employment and entrepreneurship among migrants, including refugees in highly tenuous socioeconomic situations. By tapping into volunteer networks, they provide prospective entrepreneurs with business contacts, training, and visa support. Drawing from public grants and community donations, they also provide small grants and loans for startups. Religious communities such as parishes and mosques also provide migrant entrepreneurs with opportunities to publicize their goods and services and expand their customer base (Drakopoulou Dodd and Seaman 1995; Yoo 1998; Zhou and Cho 2010). Some churches and organizations also offer childcare services that afford migrant entrepreneurs flexibility to pursue their business goals. Some also offer “rotating credit clubs” in which members pool resources and offer loans to community members in need, including prospective entrepreneurs (Bae-Hansard 2015).
The International Catholic Migration Commission (ICMC), for example, provides small grants and vocational training to Afghan refugees in the Khyber-Paktunkwha region of Pakistan. It also provides refugees with linkages with employers and it sponsors visits to shops and markets to strengthen their networks and business skills. With ICMC’s support, refugees have become successful shoemakers, carpet weavers, dressmakers, beauticians, and motorcycle repairpersons. In Jordan, ICMC supports entrepreneurship by Syrian refugees, providing vulnerable youth between 18 and 30 years of age with small grants and loans, vocational training, and support in obtaining work permits. In Malaysia, ICMC provides Rohingya refugees with small grants to promote the development and sale of art objects and crafts (ICMC 2016).
The Scalabrini International Migration Network (SIMN) also actively supports migrant entrepreneurship programs. It provides support in obtaining work authorization, business skills training, and skill certification, and provides employment referrals, microfinance, and other services. Across its 34 countries of operation, it places more than 15,000 people per year in permanent jobs.
The Hebrew Immigrant Aid Society (HIAS) provides small grants and loans, business skills training, and mentorship to refugee entrepreneurs in countries as diverse as Ecuador and Chad. Among other programs, it supports refugee women’s entrepreneurship in 12 camps in eastern Chad. It also works with Jewish Family Services to support refugee entrepreneurship through training and financial support in 20 cities across the United States.
Many faith-based organizations also partner with local governments to promote immigrant entrepreneurship. In Massachusetts, for example, Jewish Vocational Services and Lutheran Social Services partnered with the state office for refugees and immigrants to provide loans to more than 75 immigrants in the Boston area. Participants in this program have successfully opened a variety of businesses, many of which provide goods and services that cater to underserved populations.
In sum, faith-based organizations provide valuable support to prospective migrant entrepreneurs around the world. Their credibility enables them to recruit volunteers and raise funding to provide such individuals with loans, training, contacts, and visa support, among other services. These services are particularly important given that migrants often face tight labor markets and employment discrimination. Their efforts can help migrants achieve economic self-sufficiency and integrate into their host communities.
III. Conclusion and Recommendations
Many migrants around the world have limited access to adequate health care and employment. Often, migrants in the most precarious situations, such as asylum seekers and irregular migrants, face the most severe barriers as they are barred from many forms of government support. Faith-based organizations play a vital role in supporting the livelihoods of migrants, including women, children, and other vulnerable individuals. In the area of health care, faith-based organizations leverage their volunteer networks to provide care to underserved populations. They are often widely-respected and able to provide services to populations that are inaccessible to international organizations and NGOs, including detainees and refugees in camps. They also provide culturally and linguistically appropriate care, building trust between migrant communities and health practitioners.
In the area of entrepreneurship, faith-based organizations leverage their resources to provide migrants with microloans, training, and business contacts, among other services. By supporting migrant entrepreneurship, they enhance migrants’ ability to provide for themselves, their families, and their communities.
Globally, many vulnerable migrants continue to live without adequate health care and opportunities for work. To better serve such populations, the international community should support and leverage faith-based organizations’ unique resources and access to migrants.
The Global Compact on Migration should formally recognize the contributions of such organizations as well as the need to build their capacity. It should also identify possibilities for collaboration in the areas of health care and work and recommend periodic coordination meetings. In particular, states and international organizations could work with faith-based organizations to identify and rectify challenges to migrants’ health and self-sufficiency, including linguistic and cultural factors that shape the effectiveness of health interventions. States and other stakeholders could also provide training and equipment to volunteers from faith-based organizations, strengthening their capacity to reach underserved populations.
The Global Compact should also call upon states and other stakeholders to offer health care to all migrants, regardless of their legal status. It should formally recognize faith-based organizations’ unparalleled access to irregular and other vulnerable migrants and call upon authorities to work with such organizations to improve these groups’ health outcomes. Likewise, it should recognize faith-based organizations’ access to refugee camps in conflict zones and call upon states and international organizations to strengthen their capacity.
Partnerships between international organizations and faith-based organizations could also facilitate the collection of data on health and economic outcomes among vulnerable populations. The trust accorded to faith-based organizations by vulnerable migrants and government actors could greatly strengthen data collection efforts, which could lead to improved policy interventions and strengthen migrants’ livelihoods.
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