Oliver Razum

Low overall mortality of Turkish residents in Germany persists and extends into a second generation: merely a healthy migrant effect?*

Summaryobjective To test the hypothesis that as a minority with lower socio‐economic status, Turkish residents in Germany might experience a higher mortality than Germans.

Time travel with Oliver Twist

First‐generation immigrant populations in industrialized countries frequently have a lower mortality than the host population, a finding that is unexpected and often dismissed as the result of bias. We propose an alternative explanation for a real, albeit temporal, mortality advantage. We base our argument on two premises: First, that there are differences in the progression of the health transition between the immigrants’ countries of origin and industrialized host countries; and, second, that there are differences in the speed at which changes in mortality from various causes occur after migration. Mortality from treatable communicable and maternal conditions, still high in many countries of origin, quickly declines to levels close to those of the host country. Mortality from ischaemic heart disease, the most common cause of death in the host countries, takes years or decades to rise to comparable heights. This is because of the time lag between increases in risk factor levels and an increased risk of coronary death. Hence, first‐generation immigrants may initially experience a lower mortality than the host population, a point that has so far been under‐appreciated in discussions of immigrant mortality. After adopting a western lifestyle immigrants face an increasing risk of ischaemic heart disease. The increase occurs on top of a persisting risk from conditions associated with childhood deprivation, e.g. stomach cancer and stroke – the unfinished agenda of the health transition that immigrants experience.

Mindestindikatorensatz zur Erfassung des Migrationsstatus

ZusammenfassungNach wie vor fehlt eine Datenbasis, die Migranten und ihre gesundheitliche Situation angemessen repräsentiert. Einer der Gründe für diesen Mangel ist die unzulängliche Erfassung des Migrationsstatus in der amtlichen Statistik und in epidemiologischen Studien. Voraussetzung für eine adäquate und standardisierte Operationalisierung ist eine genaue Definition der Begriffe „Migrant“ und „Migrationshintergrund“. In unserem Beitrag diskutieren wir Konzepte zur begrifflichen Bestimmung und Erfassung ethnischer Minderheiten und Migranten und entwickeln auf dieser Grundlage einen Mindestindikatorensatz für die epidemiologische Forschung. Der vorgeschlagene Mindestindikatorensatz zur Erfassung des Migrationsstatus enthält die Merkmale Geburtsland von Vater und Mutter, Einreisejahr, Muttersprache, Deutschkenntnisse sowie den Aufenthaltsstatus. Zentraler Indikator zur Identifikation von Migranten ist das Geburtsland der Eltern und nicht – wie bislang zumeist üblich – die Staatsangehörigkeit. Die Klassifikation mittels der juristischen Kategorie Staatsangehörigkeit wird damit abgelöst durch die Klassifikation anhand des lebensbiographischen Ereignisses „Migration“. Mit der Migration gehen spezifische Lebensbedingungen und Handlungsanforderungen einher, die über mehrere Generationen für die Gesundheit von Bedeutung sein können. Ein Instrument zur Erfassung des Migrationsstatus muss dahingehend weiterentwickelt werden, dass es diese aus dem Migrationsereignis resultierenden Besonderheiten in der Lebenssituation widerspiegelt und möglichst alle Aspekte eines Migrationshintergrundes berücksichtigt.AbstractData on the health status of migrants are still scarce. One of the reasons for this is that migration status has not been well recorded in official statistics and epidemiological studies. In order to obtain an adequate and standardised operationalisation of migrant status, we first need an exact definition of the terms ”migrant“ and ”migration background“. We discuss approaches to the definition of terms and the surveying of ethnic minorities and migrants, and then develop a basic set of migration status indicators for use in epidemiological research. This set of indictors includes country of birth of the father and mother, year of immigration, mother tongue, German language skills and status of residence. The key indicator for the identification of migrants is the country of birth of the parents and not the nationality as was previously often the case. Thus, the classification based on the judicial category of nationality is replaced by a classification based on the biographical event ”migration“. Migration brings with it specific life conditions and challenges that can impact health across several generations. An instrument for surveying migrant status must be further developed both to reflect the special conditions of the life situation resulting from the migration experience and to take as full account as possible of all aspects of a migrant‘s history.

What do we have to know from migrants' past exposures to understand their health status? a life course approach

Empirical findings show that morbidity and mortality risks of migrants can differ considerably from those of populations in the host countries. However, while several explanatory models have been developed, most migrant studies still do not consider explicitly the situation of migrants before migration. Here, we discuss an extended approach to understand migrant health comprising a life course epidemiology perspective.The incorporation of a life course perspective into a conceptual framework of migrant health enables the consideration of risk factors and disease outcomes over the different life phases of migrants, which is necessary to understand the health situation of migrants and their offspring. Comparison populations need to be carefully selected depending on the study questions under consideration within the life course framework.Migrant health research will benefit from an approach using a life course perspective. A critique of the theoretical foundations of migrant health research is essential for further developing both the theoretical framework of migrant health and related empirical studies.

Cancer risk diversity in non-western migrants to Europe: An overview of the literature.

BACKGROUND Cancer risk varies geographically and across ethnic groups that can be monitored in cancer control to respond to observed trends as well as ensure appropriate health care. The study of cancer risk in immigrant populations has great potential to contribute new insights into aetiology, diagnosis and treatment of cancer. Disparities in cancer risk patterns between immigrant and autochthonous populations have been reported many times, but up to now studies have been heterogeneous and may be discordant in their findings. The aim of this overview was to compile and compare studies on cancer occurrence in migrant populations from non-western countries residing in Western Europe in order to reflect current knowledge in this field and to appeal for further research and culturally sensitive prevention strategies. METHODS We included 37 studies published in the English language between 1990 and April 2010 focussing on cancer in adult migrants from non-western countries, living in the industrialised countries of the European Union. Migrants were defined based on their country of birth, ethnicity and name-based approaches. We conducted a between-country comparison of age-adjusted cancer incidence and mortality in immigrant populations with those in autochthonous populations. FINDINGS Across the board migrants from non-western countries showed a more favourable all-cancer morbidity and mortality compared with native populations of European host countries, but with considerable site-specific risk diversity: Migrants from non-western countries were more prone to cancers that are related to infections experienced in early life, such as liver, cervical and stomach cancer. In contrast, migrants of non-western origin were less likely to suffer from cancers related to a western lifestyle, e.g. colorectal, breast and prostate cancer. DISCUSSION Confirming the great cancer risk diversity in non-western migrants in and between different European countries, this overview reaffirms the importance of exposures experienced during life course (before, during and after migration) for carcinogenesis. Culturally sensitive cancer prevention programmes should focus on individual risk patterns and specific health care needs. Therefore, continuously changing environments and subsequently changing risks in both migrant and autochthonous populations need to be observed carefully in the future.

Effect of Restricting Access to Health Care on Health Expenditures among Asylum-Seekers and Refugees: A Quasi-Experimental Study in Germany, 1994–2013

Background Access to health care for asylum-seekers and refugees (AS&R) in Germany is initially restricted before regular access is granted, allegedly leading to delayed care and increasing costs of care. We analyse the effects of (a) restricted access; and (b) two major policy reforms (1997, 2007) on incident health expenditures for AS&R in 1994-2013. Methods and Findings We used annual, nation-wide, aggregate data of the German Federal Statistics Office (1994-2013) to compare incident health expenditures among AS&R with restricted access (exposed) to AS&R with regular access (unexposed). We calculated incidence rate differences (∆IRt) and rate ratios (IRRt), as well as attributable fractions among the exposed (AFe) and the total population (AFp). The effects of between-group differences in need, and of policy reforms, on differences in per capita expenditures were assessed in (segmented) linear regression models. The exposed and unexposed groups comprised 4.16 and 1.53 million person-years. Per capita expenditures (1994–2013) were higher in the group with restricted access in absolute (∆IRt = 375.80 Euros [375.77; 375.89]) and relative terms (IRR = 1.39). The AFe was 28.07% and the AFp 22.21%. Between-group differences in mean age and in the type of accommodation were the main independent predictors of between-group expenditure differences. Need variables explained 50-75% of the variation in between-group differences over time. The 1997 policy reform significantly increased ∆IRt adjusted for secular trends and between-group differences in age (by 600.0 Euros [212.6; 986.2]) and sex (by 867.0 Euros [390.9; 1342.5]). The 2007 policy reform had no such effect. Conclusion The cost of excluding AS&R from health care appears ultimately higher than granting regular access to care. Excess expenditures attributable to the restriction were substantial and could not be completely explained by differences in need. An evidence-informed discourse on access to health care for AS&R in Germany is needed; it urgently requires high-quality, individual-level data.

Routine screening for intrauterine growth retardation in Germany : low sensitivity and questionable benefit for diagnosed cases

BACKGROUND Antenatal screening for fetal growth retardation has proven effective in detecting at-risk pregnancies under study conditions. It is also widely believed to improve pregnancy outcomes. We assessed sensitivity of antenatal screening routines for intrauterine growth retardation under routine service conditions in Germany. We then compared pregnancy management and outcome in small for gestational age neonates with antenatally diagnosed growth retardation to neonates whose growth retardation had remained undetected. METHODS Historical prospective study covering all 2378 singleton pregnancies with antenatal records delivered within a one-year period at a tertiary level maternity hospital in Germany. Antenatal records were linked with pregnancy outcome data. RESULTS The sensitivity of screening routines based on ultrasound and non-systematic follow-up investigations was 32% as compared to 80-90% reported for ultrasound screening under study conditions. An antenatal diagnosis of intrauterine growth retardation was associated with a 5 times higher rate of preterm delivery (p<0.001), mainly as a consequence of medical interventions to avoid fetal compromise, when compared to new-borns with growth retardation not detected before delivery; admission rates to neonatal care unit were 3 times higher (p<0.001). The proportion of low Apgar scores and low cord pH, indicating fetal distress, was not significantly different in detected and undetected cases. CONCLUSION Screening routines for intrauterine growth retardation currently used in Germany miss the majority of cases and do not contribute towards improved pregnancy outcome in detected cases. A benefit of elective preterm delivery in the management of suspected intrauterine growth retardation was not evident.

Mindestindikatorensatz zur Erfassung des Migrationsstatus - Empfehlungen für die epidemiologische Praxis

ZusammenfassungNach wie vor fehlt eine Datenbasis, die Migranten und ihre gesundheitliche Situation angemessen repräsentiert. Einer der Gründe für diesen Mangel ist die unzulängliche Erfassung des Migrationsstatus in der amtlichen Statistik und in epidemiologischen Studien. Voraussetzung für eine adäquate und standardisierte Operationalisierung ist eine genaue Definition der Begriffe „Migrant“ und „Migrationshintergrund“. In unserem Beitrag diskutieren wir Konzepte zur begrifflichen Bestimmung und Erfassung ethnischer Minderheiten und Migranten und entwickeln auf dieser Grundlage einen Mindestindikatorensatz für die epidemiologische Forschung. Der vorgeschlagene Mindestindikatorensatz zur Erfassung des Migrationsstatus enthält die Merkmale Geburtsland von Vater und Mutter, Einreisejahr, Muttersprache, Deutschkenntnisse sowie den Aufenthaltsstatus. Zentraler Indikator zur Identifikation von Migranten ist das Geburtsland der Eltern und nicht – wie bislang zumeist üblich – die Staatsangehörigkeit. Die Klassifikation mittels der juristischen Kategorie Staatsangehörigkeit wird damit abgelöst durch die Klassifikation anhand des lebensbiographischen Ereignisses „Migration“. Mit der Migration gehen spezifische Lebensbedingungen und Handlungsanforderungen einher, die über mehrere Generationen für die Gesundheit von Bedeutung sein können. Ein Instrument zur Erfassung des Migrationsstatus muss dahingehend weiterentwickelt werden, dass es diese aus dem Migrationsereignis resultierenden Besonderheiten in der Lebenssituation widerspiegelt und möglichst alle Aspekte eines Migrationshintergrundes berücksichtigt.AbstractData on the health status of migrants are still scarce. One of the reasons for this is that migration status has not been well recorded in official statistics and epidemiological studies. In order to obtain an adequate and standardised operationalisation of migrant status, we first need an exact definition of the terms ”migrant“ and ”migration background“. We discuss approaches to the definition of terms and the surveying of ethnic minorities and migrants, and then develop a basic set of migration status indicators for use in epidemiological research. This set of indictors includes country of birth of the father and mother, year of immigration, mother tongue, German language skills and status of residence. The key indicator for the identification of migrants is the country of birth of the parents and not the nationality as was previously often the case. Thus, the classification based on the judicial category of nationality is replaced by a classification based on the biographical event ”migration“. Migration brings with it specific life conditions and challenges that can impact health across several generations. An instrument for surveying migrant status must be further developed both to reflect the special conditions of the life situation resulting from the migration experience and to take as full account as possible of all aspects of a migrant‘s history.

Health, Wealth or Family Ties? Why Turkish Work Migrants Return from Germany

In the 1960s and 1970s, hundreds of thousands of Turkish workers migrated to Germany. Some settled there, others returned to Turkey after a few years. To explore how the experience of life between two cultures and in transnational families affected the decision to return, we conducted focus-group sessions with male returnees in Turkey who had spent varying lengths of time in Germany. Return was rarely based on purely economic or health-related motives; value-oriented and emotional themes almost always played a role. There were complex interactions between particular themes, e.g. perceived health status and economic success. We organised our findings into three ‘ideal types’: first, the ‘nostalgic’ returned migrant who is facing socio-economic problems in Turkey and has a transfigured notion of life in Germany which he would like to but cannot resume; second, the ‘cultural traditionalist’ who considers Turkish culture superior and left Germany without remorse after having made some money; and third, the ‘player of two systems’ who thrives in both Turkey and Germany. This typology helps to structure and understand the complex themes underlying the decision to return-migrate.

Transition in cancer patterns among Turks residing in Germany

Cancer mortality among the 2.1 million Turks residing in Germany is assumed to change from a pattern typical for a developing country towards one of an industrialised country. To test this hypothesis, we compared age-standardised cancer mortality rates among Turkish residents and (West) Germans using death registration data. In addition, we assessed proportional cancer incidence ratios among Turkish cases (n=144) in a German population-based cancer registry. All-cancer mortality 1992-1997 (per 100000) was 34.8 (n=4192) among Turkish men (Germans: 72.3) and 21.5 (n=1862) among Turkish women (Germans: 52.4). Over time, gastric and lung cancer mortality increased among Turkish men, as did breast cancer mortality among Turkish women. The proportional cancer incidence (PCIR) for stomach cancer among men was 2.9 (95% Confidence Interval (CI): 1.7-4.8), and that for breast cancer among women was 0.7 (95% CI: 0.4-1.1). Turks had an increased proportional incidence ratio for non-Hodgkins lymphoma. Our findings partly support a transition of cancer patterns among Turks in Germany.