Immigrant Workers—Where the Hazardous Jobs Are

here at the University of California, Davis, you can see some of the many things that he's involved in from his first slide. He doesn't say up here that he's also the director of the Center on Occupational and Environmental Health at UC Davis, as well as director of the Migration and Health Research Center, as well as co-director of the new UC Global Institute or Institute of Global Public Health Center of Expertise on Migration and Health. I think I've got all this approximately right. Anyway, he's a busy person. We're delighted to have him here talking about one of the things that is his specialty, and that's occupational-related health kinds of matters. In this case, with regard to immigrants. One of his colleagues from the northern part of the state is also with us on a joint mission, I think, to convert those of us here in Southern California to something rather than being a student with an industry like that. Xochitl Castaneda, who is the director of the Health Institute of the Americas, connected with Berkeley. And she'll probably come in here any minute, but I wanted to introduce her, too, if she were here. She will be here, presumably. She is also involved in this UCY Global Public Health Institute. So without further ado, Mark, welcome, and thanks for coming to speak. Well, thank you, Frank. It's really a pleasure to be here, because I know how much is going on at Irvine. And the real purpose of being here is to establish connections, to meet people, to look, particularly with the new UC Global Health Institute and the Center of Expertise on Migration and Health, but also in other areas, such as occupational health and public health in general. I also wanted to thank Belinda Campos back here, who's been really just fabulous in helping to set this up and make all these arrangements. So I'm going to talk about migrant workers and where those dangerous jobs are. Basic plan is to look at some of a perspective of global migration and causes of migration. For some of you, this may be very old hat and repetitious, but I think just to get us in the same place. And some of the demographics and economics, a bit about general social determinants of health, and then into occupational health. Focusing on US immigration, but I just want to say at the outset, this is a global phenomenon. It exists around the world. The story is repeated everywhere we look, pretty much. But for purposes of relevance and efficiency, I'm going to talk mostly about the US picture and data. And then a summary with some new paradigms, perhaps, about how to look at this. So what about the major causes of global migration? Well, the first one, just to mention, is environmental change. And this is something that is striking. It hits the news, and it's in very large numbers. You have just the Christmas earthquake and tsunami in Indonesia, with hundreds of thousands of deaths. And again, migration generated by this phenomenon in numbers we probably can't even count. The Haiti earthquake, once again, these large numbers. The story, of course, the headlines is the deaths. But what isn't there is how many people are basically disabled and have to leave or move to survive. And then Japan, just this year, once again, tens of thousands of deaths. But migration, both internal as well as international. And the last one I put up here is Bangladesh, not because there's been a recent catastrophic event, but because the slow process of climate change has a very real projected impact on global migration. And people need to be aware of this factor in this chronic context, not just in the acute disasters. So the projected 50 million environmental refugees by 2020, which is almost here, it's a fairly large number. But actually, a small one in terms of the context of global migration, as I'll point out. So the second major cause, anybody? What? Jobs. Jobs, OK. Well, that's the third. Second one we're going to talk about is political refugees. And without going through this, again, in the news, we have political refugees being generated every country that's going through an upheaval. And it's, of course, not how many are leaving, but North Africa, Afghanistan, Iraq, Burma, et cetera, et cetera. And so this is a second cause, but again, a minor one in the context of why people really move globally. 42 million estimated displaced people by the UN. Again, a lot of this being political refugees who are going for, often, safety from oppression. But as Frank Dean suggested, the real elephant in the tent is jobs, economic disparity, and improvement. That's what is driving global migration. And it's pretty succinctly spelled out here why that is. A farm worker in Oaxaca is going to make about $1.50 an hour. And if they come to California, that would be about $8.50 an hour. In other words, in a day, doing farm work in Oaxaca, you make what you make in an hour in California. And that's if the jobs exist in Mexico, which they may not. So this is driving immigration. And this is the real story globally in this succinct imagery. Now, I thought I took this out, but interestingly, we're seeing very dramatically now the necessity of immigrant labor to work in this country, as shown by this. This is one of several stories about farmers who have decided, because of the economic difficulty in the US and the high unemployment rate, that they would not have as many immigrants coming from Mexico and Latin America. And would hire locally. And it turns out that when they do that, they find that the US native born are not going to do farm work. Very simply, the work is too hard, too demanding, and they have to go back to immigrant labor. So this is not just a luxury anymore. It's a necessity for many US industries, as shown here. And let me introduce Sergio Castaneda, who just walked in, who Frank introduced earlier on. Unabstentioned. So we have the busiest border in the world. Over one million crossings a day between Mexico and the US. And largely, this is economic driven. People going to work for the most part, of course, other reasons. But we will talk about us as a country. But this, of course, is just down the road from here. San Ysidro, which is the busiest border crossing in the world. 25,000 pedestrians, 50,000 vehicles a day. Now, getting a little more into the story, of course, government, our government, to put it bluntly, has failed to deal with the migration issue, in terms of any type of comprehensive reform. And the answer has come out to be, well, let's just build this wall. As you can see several images here. And put simply, that's never going to answer this situation. What it's done is raise the cost of immigrants coming in. It's made it dangerous. It's certainly dehumanizing. But migration is being driven by other forces. And this isn't the solution. As somebody described it in this cartoon, 20-foot fences are going to lead to 21-foot ladders. And again, this is a global phenomenon because of the drivers of migration are so strong. And I love this one because it gets back to my earlier picture about who's doing the construction work and the farm work in this country, which is the immigrant population. And so when we do build these tall fences, it's probably immigrant labor. I haven't done research on that, but I wouldn't at all be surprised to find that was the case. I put this in because it's an interesting movie. And it's just to remind me again on this theme that migrant work and the occupational and non-occupational hazards of it are a global phenomenon. There are up to 200 million internal migrants in China. And this is a story about an internal migrant family in China working in Xinjiang, one of these big cities with rural pheasants coming in to do the work, and the disruptive effect on the family. So just again, a reminder that what I'm talking about really is in different contexts with different countries and different people, but the same story. OK, so where is migration? Well, this is a slide which looks at migrants as a percent of the total population from 2010. And you can see that Europe, Australia, New Zealand, North America, US, Canada are generally the major receiving regions of the world for global transnational migration. And South America, Mexico, Africa, Asia are sending countries with net out-migration. I mean, that's the picture, although we can get into the demographics in much more detail. And there's a lot of south-to-south migration going on and other types of patterns. But this is the general picture we're talking about. And of course, I'm going to focus on our own situation, which is that the majority of our migration comes from Mexico and Latin America into the US. And this is one of many traditional pictures that we look at for the so-called migrant streams. And I put this in because there's this Western stream. And certainly in agriculture, we have this idea that there's in-migration from Mexico. It goes up the West Coast and back down with the seasons, doing farm work. And there's a Midwestern stream and an Eastern stream. Now, I'm not going to dwell on this. But just recently, I saw this map of migration. And I thought, well, this is interesting. This is sort of like this migrant streams. And we have the Midwestern stream, the East Coast, and the West Coast. And it turns out that this is actually animal migration. This is Sand Hill Cranes, one of these blue migrant routes. And also, of course, the beloved monarch butterflies, who migrate from Mexico up to the United States. And it just struck me how this migration is not just a human phenomenon. And even the patterns are similar when we compare them to some of these animal patterns of migration. And it's an interesting way, when you start to go beyond disciplines and think about this phenomenon and realize how these artificial countries have created boundaries that aren't respected by people and animals, is pretty cool. OK, so just to put some numbers on this, there are something over 200 million transnational migrants in the world. Generally, we have these developing countries being countries of origin and developed economies and countries being the receiving countries. But then there's another 700 plus million internal migrants. That is mostly people moving from rural to urban areas for work. And you have this huge in China. You have it in India. You have it in the Americas. This is a large part. So put together, we have really a billion people for where migration is a major impact on their health. Now, what's clear when you look at the demographics is that the birth rates are going down in the developed countries. They're high in the developing countries. And it's migration which balances this out. I mean, this is where our workforce is coming from. So at the present time, we have about 140 young workers for every 100 retirees in the developed countries. But this number keeps shrinking as our population ages and our birth rate goes down. So it's going to be less than 100 in just a few years. And conversely, if we look at these developing countries, there's 300 plus candidates for every 100 jobs. Well, it doesn't take much to figure out what the drivers are. This is an economically driven cycle that is moving this migration. Now, this shows the proportion of international migrants in different countries. And you can see that in some countries, it's not just the dirty jobs. It's all the jobs pretty much are done by immigrants. If you go to some Middle East countries, 80%, 70% of the work is done by international migrants. The US, as we'll see, is now at 16%. So it's way down the list, but still significant. And then there's this phenomenon. The last thing I'll talk about this in a global context, which is the remittances sent by migrants. Estimated $300 billion annually. This is a huge amount of money that is shifted from developed countries to developing countries. Over 60 countries get over $1 billion a year. Over 10% of the GDP for 38 countries. This is fast. You can do it on your cell phone. You send it home to the family. What I love about remittances are that it's real foreign aid. I mean, it's helping people put food on the table, clothes, school, all those things, as opposed to what we call foreign aid, which is really government-to-government military transfers and other related type. So that's, again, a huge driver for this whole process, which is the remittances going back in the countries that are, this could be their number one, number two source of foreign income. OK, well, politically, of course, I don't have to tell anybody in the room, immigration is a hot-button topic. And I'm not going to get into this except to say it's something one has to be aware of. We hope and we work for some enlightened progress in addressing this issue. And I am certainly not going to make predictions on that except to say it's the context we work in. But I do this very much from a public health perspective. I mean, this is a health issue that I'm going to be talking about. And that's, but of course, almost daily, we have demonstrations. We have legislation. We have a lot of things happening. And for you, what's important is realizing the health impacts of some of this legislation, because it is very real. And again, that's the take or what I'm talking about. So just to remind you, finally now moving to the US and California, we are a nation of immigrants. This is going back, you can't see the timescale on the bottom, but this is 150 years. And what you're looking at is the immigration in blue and the percent of our population that has been foreign born over this 150-year time span. And immigration has been a part of our history. Historically, we've been up to about 15%. We're now 16.3% from the last census. So it's actually at a historical high. But the phenomenon of immigration as part of our population is as old as the country, except for a few native born, which is a very small percent. And when we look at the country of origin of immigrants to the US, basically about 50% are coming from Latin America. About a quarter are coming from Asia. And the rest, generally an older immigrant population from other parts of Europe, Canada, or the rest of the world. But in broad numbers, half are coming from Latin America. And that's our major source of immigrants. OK, well, that's my way of background orientation for some of you, I'm sure. It's all review, but for others, just so we're on the same page. Now I'm going to talk about immigration and work. Again, in the context that that is the major driver for people to immigrate. And I'm going to start with a little history. This is the first recorded event of immigrant labor that I can find. It's the Israelites who were slaves in Egypt to build Pharaoh's treasure cities. So this is at least 2,000, 3,000 years ago. But the phenomenon of immigrants in a country doing the heavy work, doing the hazardous work, goes back as far as we have history, pretty much. But bringing it to this country, just over 100 years ago, this book, The Jungle by Upton Sinclair, was a national phenomenon in really calling attention to the hazardous work being done by immigrants in the Chicago stockyards. And I'm rereading this book right now, and it's unbelievable. I mean, you really can't imagine how bad the conditions were of work. And it wasn't just the working conditions, it was the living conditions, it was the environment. The whole thing was really what these immigrants faced when they worked in the Chicago stockyards. And as it says here, there are utter hopelessness among this population of have-nots. This led to a lot of attention. And in fact, as is often the case in occupational health, to improvements in the work conditions because it reached it from a social perspective of the unacceptability of men and women and children working in the stockyards in very hazardous, dangerous conditions. And associated with this was the work of this person, Alice Hamilton, a physician who I think, personally, has not been recognized for her work adequately. She's sometimes called the mother of occupational health. She was in this what's now a museum, the Adams House in University of Illinois in Chicago, a founding house there founded by Jane Adams, and got interested in the work hazards of the immigrant workers in Chicago, and really was the first to recognize lead poisoning and mercury poisoning and carbon disulfide and a whole range of hazards among these workers. And she went on to become the first female faculty member of Harvard University, was an occupational medicine physician, and wrote her autobiography, which was all of these stories, and really was chided by the Europeans because there had been really nothing going on in occupational health in this country. And when she went over, I think that partly motivated her to take this on. But once again, this was looking at the immigrant workers in Chicago and the hazards that they faced. And then the last piece of history is this one, where the 100th anniversary was just this year in March. This was the Triangle Shirtwaist Factory Fire. This was a garment shop, garment factory in the Lower East Side of Manhattan. Once again, it was young immigrant women working there in very hazardous conditions. And by the way, they locked the exits, and the fire engines couldn't reach up to that height. And so a fire broke out, and there were almost 150 deaths, many of them jumping to their death from the seventh and eighth floor when this broke out, because they couldn't escape from it. And as I said, interestingly, this led to a lot of improvements in building safety and working conditions. Unfortunate tragedy. Once again, not surprisingly, it was the immigrant workers who were in this. So people come for work, and you are probably not surprised that if you look at labor force participation of men, and this is Mexican immigrants, who much of this will be about our largest immigrant population, nationwide, 94% are employed. That goes down among long-stay Mexican immigrants, and it's even less among US-born Mexican-Americans and US-born non-Latino whites. That is, people are coming here to work, and they're going to work in some type of a job, although it's often at low pay and without benefits and hazardous, as I'll talk about. But they're working at higher rates than the native population, and it gets back to the farmer who couldn't get the native population to do the farm work because it's too hard. If you're coming here to work, you're going to take the work that you get. So this is our California data. 35% of our employed people in California are foreign-born. This is the highest rate in the country. One out of three is foreign-born employee in California right now, and there's a high representation of those with low education. Foreign-born, as you can see, again, something over half from Latin America and a third from Asia, which is about our immigration statistics. So a large percent are working foreign-born in this country. It is our workforce, a substantial number and growing. So where do immigrants work? These are data for Mexicans, and this is US labor force. And you can see that this is 2004. Agriculture nationwide, 30%, although I'll tell you in California, it's more like 85% to 90% of our agricultural workers. And even since 2004, this has certainly gone up. But agriculture, construction, and transportation are the three largest industries. And then housekeeping maintenance, more women working here among our immigrant workers. So we're going to come back to this because it turns out that these are the hazardous industries in which immigrants are working, and it's reflected in the health data. Now, this is data from the Census of Fatal Occupational Injuries. It's a national registry of fatal occupational events. And you can see over the past 15 years that, in fact, our occupational fatality rate, aside from caveats on our completeness of the data, has improved. It's gone down about 25%. Why is that? Right, thank you, Frank. The largest driver is, in fact, that our most hazardous manufacturing industry doesn't exist in this country. The foundries, and the steel mills, and the other manufacturing has left the country. And we see the improvement in our occupational fatality rate because of that. But now, this is very interesting because this is, for the same time frame, the number of fatal work injuries involving Hispanic or Latino workers in this country. And you get a different picture. In fact, the actual number has gone up. And I don't show it, but the rate has also gone up. So the fatality rate, while the overall fatality rate's going down, the fatality rate and number in Latinos has gone up. And not only that, what you see, the division here, these are US-born Latinos, and this is foreign-born Latinos. And all of this increases in the foreign-born Latino population. So what's happening is we're shifting the hazardous jobs to the immigrant workers and immigrant Latinos as reflected here. And so it's nice, of course, to see the overall decline. But what we don't see by that is that, in fact, there is this shift in even higher fatality rates. Now, this shows the same data, fatality rates by industry. And on the right is the rate of fatalities. All worker fatality rate is 3.9, but in agriculture, 29. So it's seven or eight-fold higher. And remember, where the largest industry is for immigrant workers in this country, it's agriculture. So part of what's happened is we have the immigrant workforce going into the most hazardous industries. And the second most hazardous is transportation. Third, construction. These are the three highest employment for immigrant Mexicans in the US. So part of what's happened is our most hazardous industries are becoming substantially immigrant-populated. And that's reflected in the outcome in terms of fatality rates. Now, these are data on disability. And I won't go into that except to say that it's not just the fatal events that are up. It's a non-fatal one. So there are more occupational injuries among immigrants. And the disability, if there is an injury, reflected here in the Hispanics, is greater than the median. So more injuries among immigrant Latinos and more disability. Well, why is this picture happening? Why do we see increased injuries among immigrants? In part, I told you it's more hazardous jobs and tasks than construction, transportation. But is it linguistic and cultural barriers that confront the immigrant worker? Is it recent arrival of disorientation and lack of awareness of services? Is it lack of safety training and equipment? All of those are possible. And actually, what little research has been done is contradictory and suggests some in some cases and not in others. But what I want to suggest is this, which we call precarious job. And often, this translates into being undocumented. That is, the undocumented worker whose job is vulnerable if they complain, if they refuse to do something, if they in any way stand out, they can lose the job or be deported. And so they're not going to do that. I mean, they're the vulnerable worker. And this is really the overriding reason, I think, for a lot of this increased risk among immigrant workers. So this is from some research that I did with collaborators in Spain, which is very interesting because it looks at this question. And this is a national study in five different centers of immigrant workers in Spain. This is for women. And what this showed was that your documentation, your work documentation, was a major determinant of how your ill health or your health perception in this population. That is, if you were undocumented or only had a temporary document, your health status was much worse, more harmful, than those who had permanent documentation and had been in Spain over three years. And the suggestion, again, was that the security of work, not even being a citizen or legal status, but just work security, had a major influence on self-perceived health status. And the same was seen in men. This is, again, those over three years and under three years in Spain. But the undocumented are the ones that seem to be most vulnerable in terms of self-perceived health status. And we're collaborating with them now to look at this in this country. But it gets at this precariousness. If you're precarious, if you're vulnerable, if you don't have any job security, the hazards of work increase in your situation. So this is some other interesting research that I did, semantical in Spain. This is from the European Community Respiratory Health Study. One of the findings of this study was that household cleaners are a cause of asthma. You know all that hazardous stuff that they use to clean bathrooms and tiles and whatnot. Well, it turns out that that does affect your lungs. And in this large study, 3,500 people associated with increased incidence of asthma symptoms and medications. And so I came there, and I said, well, you guys looked at which of these are immigrant workers and non-immigrant workers. That'd be interesting. And about 10% of this population, the European Respiratory Health Study, was immigrant. And so we looked at that. And it turned out that among the blue collar workers, this was exposure to respiratory toxins, which was independently measured for all these people in this study. Among men and women, if you were an immigrant, you had higher exposure to these respiratory toxins. And it just confirms, again, this association that the most hazardous, the dirtiest jobs proportionally end up higher for the immigrant workers, for all the reasons that probably could be dissected. But at the end of the day, you see this increased picture. And we also looked at respiratory outcomes and saw those associated with being immigrant, independent of the other factors, risk factors. So I'm going to talk now a little about different selected industries in the US and just some data on them in terms of this whole picture. Now, I want to start by saying that there hasn't been a lot of research on migration and occupational health. In fact, there was a national paper where they surveyed all the peer-reviewed articles for 13 years, I think, on migration and occupational health. It was 46 articles, 46 in the world's literature, English and Spanish. So this has not been an area of a lot of research. But maybe I can challenge or stimulate some of you to help fill in some of the gaps. Well, agriculture, of course, is, as we've seen, a major source for immigrant labor in California, 85%, 90% Latino or farmworker population. And just to emphasize that, this has always been an industry populated by immigrant workers. If we go back to the early 1900s, we had European immigrants from Italy and Ireland coming over and working in California fields. And in the 30s, we had internal migrants, interestingly, coming from the Midwest to California. And now we have our Latino immigrants coming in and doing farmwork. So this is an old story with just the dates and the ethnicities that have changed over time. And the injuries in agriculture that collectively go into those increased fatality rates and injury rates are broad, enormously broad. So everything from respiratory to skin disease, infectious diseases, heat stress, et cetera, et cetera. I don't really have time to get into this. And it's one of the things I do a lot of research on. But obviously, this is the burden that our immigrant workers face when doing agriculture. This is now about 10 years old. But it was a statewide survey of health status of farmworkers in the state, with about 900 and some farmworkers selected in a very careful way to represent the state. And what it showed was not just high rates of acute injury, but chronic diseases, including heart disease, hypertension, hypercholesterolemia, anemia, in this population. So it's very real by the best data that exists. These are data for non-fatal injury rates in agriculture, a little dated now. But what you see is there's been some improvement. But it continually remains 25% or 40% higher than the all-industry average. So agriculture is more in. And this is a study of proportional mortality rates for farmworkers in 24 states that collect these data regularly. And again, these PMRs, except for suicides and firearms, were not elevated. For all other causes, pretty much elevated, showing the breadth of causes of acute fatalities in farmworkers. It's certainly not pesticides. In fact, we rarely have deaths from pesticides. But it's falls, it's injuries, it's machinery, it's animals. So three years ago in May, this woman, Maria Isabel Vasquez Menes, died working just outside of Sacramento. It was a hot day. It was in the 90s. And she came to work and started developing symptoms. And of course, she was a recent immigrant and didn't have a lot of recourse and was basically told to keep working. After about three hours of work, she got water. But her symptoms progressed. And eventually, she was told to go home. And that if she didn't feel well, to go to a clinic and, by the way, tell them you were at home and weren't feeling well when you go into the clinic. She went into the clinic, at which time her temperature was 104 degrees. And she was in the early stages of heat stroke. And they sent her to a medical facility. But by that time, it's a disorder with a 50% mortality rate. And she died three days later after several seizures. And I show this because, one, it's clearly a tragedy. But two, it's a completely 100% guaranteed preventable tragedy. Nobody should die from heat stress. And yet, we have deaths every year from heat stress in California and across the country. And I think it illustrates this precarious worker phenomenon. This is somebody who knew that if she complained or she tried to stop working or anything, that her job was vulnerable. And just in case anybody still has dry eyes, she was also pregnant at the time she died. And her fiance was working in the fields near her. So I mean, this was a multiple compound tragedy. But it always illustrates for me, again, this phenomenon of the vulnerable precarious worker, the one who can't complain, who doesn't have recourse, and again, dies from something bad. So people have looked at this heat stress mortality. And it's something we're actively doing research on. And it is significantly increased in agricultural workers. It's about 20 times as common as all industry. And it's not just that it's hot in agriculture, because we have other hot industries in which we don't see this. For one, the military, where basically they're out in the desert. But they're protected. They're getting water. They're getting hydrated. They're getting what's needed to prevent this. But even other industries, manufacturing. So this is a unique, well, it's one outcome that we see greater in agriculture. But it reflects all these things about the vulnerability of the immigrant. Another industry which you may encounter when you go to the local Home Depot or other areas is day labor. This, again, is a common occupation for immigrants, particularly undocumented immigrants who are out there getting day jobs. And there has been some research looking at this. This is a study that was done outside Washington, DC, where they went door to door and got a spectrum of immigrant workers who sorted out into construction, maintenance, restaurant, motel work. And so this population, they looked at their health experience. Only one fifth had health insurance. But importantly, in the previous three years, there were 47 disabling injuries, which is about 50% higher than the national rate. So in this effort to get a representative sample, and this is one of the better studies, even with all its problems, a 50% greater rate of disabling injuries in the population. And then, I didn't point out at the bottom here, over half didn't file workers' compensation claims, even though 100% are entitled to workers' compensation. The system conspires against that. And we see this over and over in studies on immigrant workers, that workers' compensation system is failing them. But also, these were serious injuries, 13 days of lost work as a median. Almost a third had to change their job because of the injury. And then, they looked at a number of things which are not associated with being injured. English speaking ability, number of jobs, job tenure, receiving safety training. So the basic picture was, in these workers, high occupational injury rate, more disabling, having to change jobs, and not getting workers' compensation. Sort of a picture of day labor or outcomes. Construction work is, again, very common among our immigrant workers. And this is a study that looked at that census of fatal occupational injuries. And it's interesting because, well, first of all, Hispanics are 16% of the constructional workforce, but almost 24% of the fatalities. And then, when they looked within job category in construction workers, so they looked at the fatality rate of being a Latino versus a non-Latino if you were a roofer or if you were a carpenter. And for all of these, there was significantly greater risk of an occupational fatality if you were a Latino worker in that job category versus being a non-Latino worker. So once again, these factors that we don't see from these data but are associated with higher fatal injury rates among the immigrant workers. We can assume the immigrant being Hispanic and being Latino. OK, this doesn't show up really well, but this is from a recent demonstration. And if you can read that, we are workers, not slaves. These are domestic workers where, recently, there's been a lot of attention to the, safe to say, horrendous working conditions that can exist around the world for domestic workers. And they've tried to call attention to this to improve the conditions. But you often have slavery-type conditions for workers in some countries who are immigrating there. So December 6, 2010, the UN adopted a statement on new protections for migrant domestic workers. Again, recognition getting to the United Nations that this is a global problem and that it needs some attention. But then, January, this type of headline, migrant domestic workers. I was in a prison, a cage, just like a slave. Migrant domestic workers in the UK subjected to meager wages, violence, sexual abuse, food rationing, usually by the middle class employers. And I could show you more of these stories, but I just want to call attention to the fact that women are enduring the hazards of immigrant work more in domestic settings and hotel work and so on. And then at the extreme is really the criminal treatment of immigrant workers, such as this case that was in the US a couple of years ago. This was actually an immigrant herself who was convicted of 20 counts of fraud for selling fake asbestos removal training certificates to foreign workers. So these are foreign workers who are basically told, for so much money, I'll give you a certificate that you're certified and trained in how to remove asbestos. And then you can go out and do asbestos removal jobs with no training or any preparation. And this, of course, there was no follow-up. They don't know about where these people were or their exposure or their health outcomes, but we, of course, know about asbestos work. And asbestos removal work is probably the most hazardous type of asbestos work there is now because of the potential for very significant exposure. And I put this in, again, as one example of the extreme into the criminal activity that could exist. So where are things going? Well, this is a report, a global consultation on migrant health in the United Nations. And it's people trying to get together, the IOM and UN, say, what can we do about this? How can we address this situation? And they came up with this operational framework of priorities that they recommend need to be done. The first of these is really to look at the data. Can we identify the status of migrant workers in terms of these health outcomes, occupational and non-occupational? We need health systems that are sensitive to migrant status so that we're not excluding migrants. We're not preventing them from coming in. We're really recognizing they have health needs and can get those. It needs to be done in policy legal frameworks and, ideally, in partnerships with a multi-country perspective. So it's not just the receiving countries, but it's binational or multinational efforts that are needed. So all of this is really to say, yes, this is a problem. We recognize it. And we need to think about it differently. We need a new paradigm to understand this is part of our interconnected world and that we have to. So this is how this paradigm shift has been looked at from traditional approaches of migration, which, unfortunately, is a mentality that still exists. It's security. It's put up the wall. It's exclude people. It's quarantine. It's protect the nation to thinking more in this multi-dimensional approach, reducing inequities, treating all workers the same, not having separate laws for immigrant workers and non-immigrant workers, social protection and health, again, being a multinational perspective as we address this. So it's a start. But it's, again, saying we need to rethink this. And what I've been presenting is mostly just the occupational health side. But, of course, there's all the non-occupational. So I just end with this quote from Kofi Annan, the former Secretary General of the United Nations, who said, we now understand better than ever that migration is not a zero-sum game. In the best cases, it benefits the receiving country, the country of origin, and ourselves. And I really think that is true and that that's the goal we need to strive to. I just want to mention, for those of you who might be interested, we have three new academic courses through our university extension. One is Public Health Perspective on Migration and Health. One is on Clinical Approaches to the Immigrant Patient. And one is Best Practices in Health Intervention. Anyone who's interested, I have some brochures that you can talk to me. And thank you very much. And I don't know if we have time for questions, but a great audience. Thank you.