"For a better life..." A study on migration and health in Nicaragua; Cecilia Gustafsson $(function(){PrimeFaces.cw("Tooltip","widget_formSmash_items_resultList_43_j_idt799_0_j_idt801",{id:"formSmash:items:resultList:43:j_idt799:0:j_idt801",widgetVar:"widget_formSmash_items_resultList_43_j_idt799_0_j_idt801",showEffect:"fade",hideEffect:"fade",target:"formSmash:items:resultList:43:j_idt799:0:fullText"});});

"For a better life..." A study on migration and health in Nicaragua; Cecilia Gustafsson $(function(){PrimeFaces.cw("Tooltip","widget_formSmash_items_resultList_43_j_idt799_0_j_idt801",{id:"formSmash:items:resultList:43:j_idt799:0:j_idt801",widgetVar:"widget_formSmash_items_resultList_43_j_idt799_0_j_idt801",showEffect:"fade",hideEffect:"fade",target:"formSmash:items:resultList:43:j_idt799:0:fullText"});});
“For a better life…”
A study on migration and health in Nicaragua
Cecilia Gustafsson
Department of Geography and Economic History
Umeå University, Sweden
GERUM 2014:2
GERUM-Kulturgeografi 2014:2
Institutionen för geografi och ekonomisk historia, Umeå Universitet
Department of Geography and Economic History, Umeå University
901 87 Umeå, Sverige/Sweden
Tel: +46 90 786 63 62
Fax: +46 90 786 63 59
Web: http://www.geoekhist.umu.se
E-mail: [email protected]
This work is protected by the Swedish Copyright Legislation (Act 1960:729)
ISBN: 978-91-7601-192-8
ISSN: 1402-5205
© 2014 Cecilia Gustafsson
Cover photos: ©Tom Dowd│Dreamstime.com
Electronic version: http://umu.diva-portal.org/
Printed by: Print & Media
Umeå, Sweden 2014
Acknowledgements
I owe many thanks to a great number of people for having been able to conduct
this research and write this thesis. It has been a rather long, often joyful but
also occasionally very arduous, journey that began with a phone call in 2005
from the person who would become my main supervisor – Gunnar Malmberg
– asking if I would like to be part of a research proposal on the theme of
migration and health in Nicaragua. So, to begin with, thank you so much,
Gunnar, for giving me that opportunity and for believing in me!!! Especially
seeing as I’d never been to Latin America, didn’t speak Spanish, and had no
experience of working with statistical data… Now, almost ten years later, the
project has finally come to an end! I know that part of your decision to call me,
Gunnar, was based on a conversation with my former graduate thesis
supervisor and subsequent PhD co-supervisor, Aina Tollefsen. Had it not been
for you, Aina, I don’t think Gunnar would’ve made that call, and I also don’t
think I would’ve ventured on this journey at all. So, a great thank you, Aina,
for your encouragement that began during the work on my graduate thesis
and has continued ever since. You two – Gunnar and Aina – have made the
best team of supervisors a PhD candidate could wish for. Thanks ever so much
for your encouragement, support, patience, and for sharing your intellectual
expertise and specific skills with me during countless hours of talks, or handson work at the computer and with the manuscript. You both have also joined
me in my travels to Nicaragua; thank you for the fun times and for the work
we did there together!
Key in this whole process has of course been the Department of Geography
and Economic History at Umeå University. I would like to thank the whole
Department for making this project possible from the start, as well as for the
support over the years. Great thanks to all the Heads – Kerstin Westin, Urban
Lindgren, Dieter Müller, Einar Holm, and Ulf Wiberg – and special thanks to
Kerstin and Dieter for reading and commenting on the first manuscript of this
thesis. Thank you also Rikard Eriksson and Emma Lundholm, for reading and
approving the final version of the thesis. Many thanks to the “TA staff” over
the years – Lotta Brännlund, Erik Bäckström, Ylva Linghult, Fredrik Gärling,
Maria Lindström, and Margit Söderberg, for easing the PhD work process and
teaching. To all my former and current co-doctoral students – thank you so
much for the fun times and the warm support! I’ve really enjoyed getting to
know you all and being part of the PhD group! Special greetings to the
“Monday-lunch group”: Jenny, Erika, Linda, Katarina and Madeleine (I’m
finally one of you now!). And, to Anne Ouma and Erika Sörensson for sharing
an interest in development geography.
i
Two actors to whom I am deeply indebted and grateful for making this
research possible are the Centre for Demographic and Health Research
(CIDS) and the organization CHICA in León and Cuatro Santos, Nicaragua.
Thank you ever so much for initiating and carrying through the research
together with my colleagues and me. Without your collaboration, a large part
of the research would not have been possible to conduct to begin with!
Quisiera agradecer a todos los que han colaborado con este trabajo en el
CIDS y CHICA! Special thanks to the heads of CIDS, Rodolfo Peña and Eliette
Valadarez, and to Elmer Zelaya at CHICA. And many thanks to all other staff
members at CIDS and CHICA who helped with the study and with other
practical matters –Andrés Herrera, Wilton Pérez, Mariano Salazar, Claudia
Obando Medina, William Hugarto, Margarita Chévez, Maria Mercedes Orozco
Puerto, Aleyda Fuentes, Francisca Trujillo, Maria Teresa Orozco, Doña
Azucena, Marlon Meléndez, Rolando Osejo, Alland Delgado and Ramiro
Bravo, as well as the numerous fieldworkers involved in the survey study.
Thank you also, Yamileth Gutiérrez, for transcribing the interviews. And, to
Mariela Contreras, Uppsala University, for the time we spent together in field
and for letting me use some of your photos in the thesis. I am also deeply
indebted and grateful to the Nicaraguan men and women who participated in
the interviews and survey in this study. Even though many of you are not likely
to be reached by these words, I would like to express my deepest gratitude to
you all, for taking the time and effort to share your experiences with me.
Muchisimas gracias a todos los que participaron en el estudio!!!
Several other researchers at Umeå University have also been supportive
during the research process. Many thanks to the group of Swedish-Nicaraguan
researchers at, or connected to, the Division of Epidemiology – particularly
Ann Öhman, Kjerstin Dahlblom, Gunnar Kullgren, and Ulf Högberg – for
sharing your expertise on Nicaragua, the collaboration between Umeå-León,
and health surveys. Thanks also to Hans Stenlund and Erling Lundevaller for
sharing your statistical knowledge. Also, a big thank you! to Linda Berg,
UCGS, for reading the first manuscript of this thesis, and for providing many
good ideas for how to improve the text.
I would also like to thank the research funder, the Swedish International
Development Cooperation Agency/Department for Research Cooperation
(Sida/Sarec), for the initial grant. Thanks also to JC Kempes Minnes
Stipendiefond for smaller grants over the years.
Last but not least, a great thank you to my beloved family and to my dearest
friends for standing by and cheering me on all these years. I hope my mind
will be a little less occupied with work from now on so that I can dedicate it
more to you…
Cecilia Gustafsson, December 2014, Umeå
ii
Table of Contents
List of figures
List of tables
Abbreviations
vii
viii
ix
PART I: SETTING THE SCENE
xi
1. Introduction
La Americana
La Bestia
Points of departure and focus of the thesis
The migration-health nexus
Health geography
The “Western” bias in research on migration and health
The migration-health nexus within the context of social transformations
and social inequalities
Aim and research questions
Framing the study: the research collaboration, and the Health and
Demographic Surveillance Systems in León and Cuatro Santos
Delimitations
Outline of the text
2. Theoretical framework
Geographical and sociological perspectives on health
Putting health into place
A holistic/integrative perspective on health
Social and critical perspectives on health
Embodiment, emotions and health
Stress, health and coping
Health care
A social transformation and relational perspective on migration
Migration, social transformations and development processes
Mobile livelihoods
Translocal geographies and transnational social spaces
The interrelations between migration and health
The migration-health nexus as a bi-directional process
The “globalized” body
Migrant health
Transnational families and health
Recapitulation: a critical framework for analysing the migration-health nexus
iii
1
1
1
2
2
5
7
9
12
13
14
15
17
17
17
19
20
24
26
26
28
28
31
33
34
34
35
36
40
42
3. Materials and methods
A mixed-methods case study
Case study methodology
Mixed-methods research
The fieldwork
Getting to know the field, and holding test interviews
The interview study
The interviewees
The interview situation
Qualitative research approaches and methods of analysis: the biographical
approach and constructivist grounded theory
The two-step survey study
The HDSS in León and Cuatro Santos
Survey step 1: singling out individuals
Survey step 2: construction of sample and questionnaire
The survey procedure
The survey data and statistical analysis
The last fieldtrip: feedback and follow-up
Reflections on conducting mixed-methods research
4. Nicaraguan landscapes: “La vida es dura”
45
45
45
47
52
53
54
55
61
63
67
67
70
71
75
78
81
81
Crucial moments in the past: socio-economic transformations 1520-2006
The colonial era and the post-independence period
The Somoza dynasty and the Sandinista revolution
The Sandinista years and the Contra war
The Conservative era and the return of Daniel Ortega
Living conditions during the fieldwork period
The Ortega administration
The socio-economic situation
Migration patterns
The study settings of León and Cuatro Santos
Summary
85
86
87
91
95
99
103
103
104
112
118
119
PART II: RESULTS FROM THE EMPIRICAL MATERIAL
123
Introduction to the empirical chapters
The complexity of migration-health relations
Mobile livelihoods, migrant health and translocal lives
Vulnerability, suffering and coping
125
125
125
126
iv
5. Mobile livelihoods and health dynamics
Introduction
Prior experiences of migration
Qualitative results: migration biographies and networks
Survey results: migration networks, migration histories and intentions
for future migration
Summarizing comment
Motivations for moving and staying
Survey results: stated motives behind intended moves
Qualitative results: the troubles making a living and striving for a better life
Particular health concerns as motivating factors
Social support, remittances and health
Survey results: help within social networks
Qualitative results on remittances
Who receives remittances? Results of the survey study
Summary and conclusions
6. Health on the move
Introduction
The journey
Passing through the jungle
“Illegal” border crossings
“Legal” border crossing
Life in the new place
New environments
Working and living conditions
Access to health care and medicine
Returning “home”
Happy returns
Ambivalent returns
“Shameful” return
Results of the survey study: the migrants’ situation abroad
Summary and conclusions
7. Coping with translocal lives
Introduction
Divided families
Emotional impacts of separation
Changes in family relations
Survey results: migration and self-rated health
Parenting and caring at a distance – tensions and coping strategies
Trying to maintain relations
Making plans
v
127
127
128
129
131
137
138
138
140
163
172
174
182
188
194
197
197
198
198
199
206
207
208
213
222
229
229
229
230
231
232
235
235
236
239
246
255
260
262
263
Sending dollars shows care
Contact within transnational social spaces
Summary and conclusions
264
265
267
PART III: CLOSING OF THE THESIS
271
8. Concluding discussion
273
273
273
Tracing health within the migration process
Migration, health and social transformations in Nicaragua
Complex migration-health relations – the importance of contextualization
and social differences
The embeddedness of health in mobile livelihoods
The importance of social networks and translocal social support for health
The stresses of migration – migrants’ vulnerability and suffering
The health effects of separation and coping strategies
Advantages and disadvantages
274
274
276
278
280
281
Resumen en español
283
Sammanfattning på svenska
294
References
299
Appendix: Survey questionnaire
vi
List of figures
Figure 1:
Map of Nicaragua and the study settings
p. x
Figure 2:
Study areas in León municipality, 2006
p. 68
Figure 3:
Study areas in urban León, 2006
p. 68
Figure 4:
The HDSS in Cuatro Santos, 2005
p. 69
Figure 5:
The two-step survey
p. 75
Figure 6:
Family members in other places (who)
p. 132
Figure 7:
Family members abroad (country of residence)
p. 133
Figure 8:
Place of birth
p. 135
Figure 9:
Expressed intentions to move
p. 136
Figure 10:
Stated motives behind intensions to move
p. 139
Figure 11:
Perceived social support
p. 175
Figure 12:
Type of help received
p. 177
Figure 13:
Use of money remittances
p. 177
Figure 14:
Origin of money remittances
p. 178
Figure 15:
Sender of money remittances
p. 178
Figure 16:
Received help during illness period
p. 179
Figure 17:
Origin of help during illness period
p. 180
Figure 18:
Provider of help during illness period
p. 180
Figure 19:
Contact with emigrated relatives (frequency)
p. 266
vii
List of tables
Table 1:
The interviewees
p. 56
Table 2:
The study population and sample frame
p. 72
Table 3:
The sample
p. 73
Table 4:
The respondents
p. 77
Table 5:
Variables in the data
p. 79
Table 6:
Weights
p. 80
Table 7:
Nicaragua’s modern history; selected indicators
and major events
p. 122
Table 8:
Location of dispersed family members
p. 133
Table 9:
Immigration status of emigrated relatives
p. 134
Table 10:
Migration history
p. 135
Table 11:
Exchanges of help
p. 175
Table 12:
Type of help during illness
p. 181
Table 13:
Logistic regression: “Remittance-receiver”
p. 191
Table 14:
Logistic regression: “Remittance-receiver”
p. 191
Table 15:
Logistic regression: “Remittance-receiver”
p. 192
Table 16:
Logistic regression: “Remittance-receiver”
p. 192
Table 17:
Logistic regression: “Remittance-receiver”
p. 193
Table 18:
Self-rated physical and mental health
p. 256
Table 19:
Logistic regression: “Good self-rated physical health”
p. 257
Table 20:
Logistic regression: “Good self-rated physical health”
p. 258
Table 21:
Logistic regression: “Good self-rated mental health”
p. 259
Table 22:
Way of contact with emigrated relatives
p. 266
viii
Abbreviations
CGT
Constructivist Grounded Theory
CHICA
Coordinator of Austria’s development co-operation
(Coordinación de Hermanamientos e Iniciativas
de la Cooperación Austríaca)
CIDS
Centre for Demographic and Health Research
(Centro de Investigación en Demografía y Salud)
CSDH
Commission on Social Determinants of Health
GT
Grounded Theory
HDI
Human Development Index
HDR
Human Development Report
HDSS
Health and Demographic Surveillance System
HIPC
Initiative for Heavily Indebted Poor Countries
IMF
International Monetary Fund
INIDE
National Institute for Information and Development
(Institutio Nacional de Información de Desarrollo)
IOM
International Organization for Migration
MDG
Millennium Development Goal
MM
Mixed-methods (research)
NGO
Non-Governmental Organization
SAP
Structural Adjustment Programme
UN
United Nations
UNDP
United Nations Development Programme
WB
World Bank
WHO
World Health Organization
ix
Figure 1: Map of Nicaragua and the study settings.
x
PART I:
SETTING THE SCENE
This part includes four chapters that together set the scene for
the empirical study. The first chapter introduces the thesis and
the research topic, the second provides the theoretical
framework and presents previous research, the third describes
the study’s empirical material and methods of analysis, and the
fourth presents the context of the study – Nicaragua and the two
study settings of León and Cuatro Santos.
View of León, Church of el Calvario.
Photo: Otto Dusbaba, Dreamstime.com
xi
Urban centre of San Pedro, Cuatro Santos.
The Cathedral of León.
xii
CHAPTER ONE
Introduction
La Americana
In the documentary film “La Americana”1, a Bolivian woman named Carmen tells
her story of working as an undocumented immigrant in the United States. Carmen
had gone to the US because her daughter Joanna had been injured in a traffic
accident when she was a little girl. High expenses for Joanna’s health care led to
serious debt for Carmen, and she saw no other way out than to go to the US to work.
She left Joanna in the care of her grandmother and travelled via Mexico to the
American border, which she crossed hidden in the back seat of a car. Carmen’s hopes
were to earn a great deal of money to repay the debt and cover her daughter’s present
and long-term medical needs. After working six years in New York, she decided to
return to Bolivia for Joanna’s fifteenth birthday. Upon her return, though, Carmen
soon realized that the money she had earned in the US wouldn’t last long due to the
high medical costs and living expenses. Still, she said she didn’t regret going back,
since both she and her daughter had suffered a great deal emotionally during their
separation.
La Bestia
In April 2013, on IOM’s web page2, Niurka Piñeiro told the story of José Luis
Hernandez, a 19-year-old Honduran, who “had lost a leg, an arm and four fingers of
the other hand after falling off of La Bestia, or the Beast, as Central American
migrants aptly name the train that leaves the southern Mexican city of Arriaga and
travels north to Reynosa, just across the border from McAllen, Texas”. José’s goal,
recounts Piñero, was “to help my family build our own house, maybe even buy a car.
I just wanted a better life. And with that dream I left my home; the dream of helping
my family. And here I am a burden to my family”. José believed he had fallen from
the train after falling asleep on the roof, but, as Piñero denotes in her article, “many
other migrants say that if you don’t pay US$100 or more to the members of the
‘maras’ or gangs that hop on and off La Bestia they will push you off the moving
train”.
*
*
*
*
*
*
*
1 By People’s Television, directed by Nicholas Bruckman (2008). See: www.la-americana.com.
2 See the International Organization for Migration’s (IOM) blog, “The Migration Blog: Read all about it”,
12/04/2013: http://weblog.iom.int/beast-turns-dreams-nightmares. The situation for migrants travelling with
La Bestia is also vividly portrayed in the award-winning film “Sin Nombre” (2009) by Cary Joji Fukanaga.
1
The connections between migration and health that are suggested by Carmen
and José Luis’ stories are examples of what this thesis is about. Their accounts
capture many important dimensions also relevant in this study’s context of
understanding the migration-health nexus: the practice of mobile livelihoods
(migratory lifestyles) for making a living in low-income countries, the
difficulty affording health care and medicine in countries with non-inclusive
health care systems, the importance of social networks for care and money,
the dangers during transit and illegal border crossings, the complications of
living and working without legal documents in a new country, and the
psychological costs of family separation. On the following pages, these aspects
of migration-health relations – and many more – will be explored and
analysed in the context of Nicaragua. Nicaragua is a country where migration
is a predominant feature with deep historical roots. Migrant workers’
remittances have over the years become an increasingly important source of
income for the population, partly used to pay for health care and medicine as
the public sector is unable to provide adequate services for all.
Points of departure and focus of the thesis
Health and migration are intimately linked. Given that migration is an inherently
social and geographical process, and that health and health care are socially and
geographically patterned, this is hardly surprising. Yet much more work needs to be
done to clarify the relationships. (Gatrell & Elliott, 2009: 178)
The migration-health nexus
It is commonly acknowledged that there are intimate linkages between
migration3 and health4. These linkages are relatively well-researched, within
both the medical and social sciences (see e.g. Evans 1987; Carballo & Mboup
2005; Jatrana, Graham & Boyle 2005; Gatrell & Elliott 2009; Schaerström,
Rämgård & Löfman 2011); yet, as I will return to in a moment, far more
research is indeed needed in order to disentangle these intricate relations.
As Gatrell and Elliott (2009) mention in the quote above, migration and
health are social and geographical processes that naturally influence one
another. The act of moving influences all areas of life, including health; and
3 In this thesis migration is defined as moves undertaken by individuals to new places of residence for any
length of time (see Chapter 2 for further discussion). Internal migration implies moves within the borders of a
country, whereas international migration refers to movements across national borders (see e.g. Boyle, Halfacree
& Robinson 1998).
4 In this thesis I apply a holistic, social and critical understanding of health, much related to the World Health
Organization’s (WHO) definition that reads “a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity” (WHO 2006: 1) (see Chapter 2 for further discussion).
2
health, as part of life, naturally also influences migration patterns. Thus,
health is also a geographical process. As people move between physical and
social milieus, their health, as well as their access to health care, may be highly
influenced. Moreover, migrants’ family members may also be affected in the
process. Hence, “health […] conditions are powerfully entangled with people’s
trajectories into, within and out of, different spaces and places” (Smith &
Easterlow 2005: 185). These relations between migration and health are at the
core of what I call the migration-health nexus in this thesis.
A common and useful way to conceptualize the migration-health nexus is to
look at it from two sides; that is, to distinguish between, how migration affects
health (M  H) on the one hand, and how health affects migration (H  M)
on the other (Jatrana, Graham & Boyle 2005, with reference to Hull 1979).
One example of the first type of interaction (M  H) is how a person’s or
group’s life and health situation in previous places of residence (e.g. countries,
towns or smaller communities) may influence the person’s/group’s current
health situation at the destination, or influence the health systems in
destination countries (commonly referred to as migrants’ health footprints).
Another example is how the act of moving per se may influence the health
status of migrants (the stresses of migration). A final example of M  H
interactions concerns how the establishment and living conditions in the
destination country may influence the migrant’s health situation and his/her
access to health care (life after migration). Turning to the second side of the
migration-health nexus (H  M), one important example is how the health
situation of migrants may influence their propensity to migrate (denominated
health selectivity in migration). Another example is how health problems may
spur migration in order to reach health care or social support (migration for
care) (ibid; see also e.g. Gatrell & Elliott 2009). As the examples above show,
the migration-health nexus is commonly viewed as bi-directional, in the sense
that migration and health may affect each other. This thesis deals with the bidirectional connections between migration and health, i.e. both the diverse
impacts of migration on health, and the different impacts of health on
migration, in the case of Nicaragua.
The existing literature on the linkages between migration and health can be
divided into studies investigating health in relation to either internal
migration (migration within countries), or international migration (migration
across national borders). According to McKay, Macintyre and Ellaway (2003),
the research on internal migration and health is dominated by studies on
geographical variations in health, with the aim to determine the main
predictor of health outcome (e.g. place of birth or place of residence). Many
studies are also conducted on the effects of moving between areas of different
character (e.g. from rural to urban areas, or from well-off to more deprived
3
areas). A third area focuses on selective migration, that is, the movement of
“healthy” or “unhealthy” migrants. The research on international migration
and health, on the other hand, is primarily focused on comparing the health
patterns of migrant groups to those of the host population, or to non-migrants
still residing in the sending country (for example studies on mental health and
mortality due to, e.g., cardiovascular disease and cancer). This thesis explores
health in relation to both internal migration (moves within Nicaragua) and
international migration (moves across the border of Nicaragua), and thus
involves both of these vast research fields.
The picture in the literature remains unclear as to the effects of migration on
health, and vice versa. The vast variation in migration patterns, in migrant
groups, and in research design makes it difficult to draw any overall
conclusions. The effects seem to depend on “who is migrating, where they
migrate from, where they migrate to, and what health outcome is measured”
(McKay, Macintyre & Ellaway 2003: 18; see also e.g. Schaerström, Rämgård
& Löfman 2011). In this study, I do not attempt to establish whether or not
migration is beneficial for health, since the effects are so diverse and contextdependent. Instead, this thesis aims to explore and analyse the manifold
relations between migration and health that exist in the case of Nicaragua,
and the surrounding factors that are of importance for the enactment of
these relations. The ambition of this study is therefore to capture the ways in
which different kinds of migration experiences – in terms of, for example,
economic circumstances, household formations, family relations, gender and
immigration status – relate to health during different stages of the migration
process.
Much contemporary migration in Nicaragua is practised as a strategy for
making a living, that is, as part of people’s livelihoods. In order to characterize
these movements I apply the concept of “mobile livelihoods” (e.g. Olwig &
Sørensen 2002), which emphasizes the embeddedness of migration in lives
and livelihoods, and the importance of multiple geographical settings for
making a living5. This concept is closely aligned with recent trends in
migration studies that emphasize the processual and relational nature of
migration. Migration is therefore understood in this thesis as a relational
process that binds together everyday lives across spaces, places and scales,
thus creating “translocal geographies”6 (Brickell & Datta 2011). Based on this
5 Another similar concept is that of “multi-local livelihoods” (Thieme 2008), which also stresses the importance
of migration, other types of mobility, and multiple geographical settings in people’s strategies for making a
living. See Chapter 2 for further discussion, including the distinction between “migration” and “mobility”.
6 The concepts of “translocality”, “translocalism”, and “translocal geographies” highlight the geographies of
everyday lives across spaces, places and scales, without giving preference to any particular situatedness (for
instance the nation, as in “transnationalism”) (Brickell & Datta 2011). “Transnationalism” (see e.g. Vertovec
2009), as well as the idea of “transnational social space” (Faist 2000), are also important conceptualizations in
4
understanding, I aim to investigate health in relation to the whole process of
migration – health is, thus, “traced” within the migration process. I therefore
make use of the frameworks developed by Haour-Knipe (2013) and
Zimmerman, Kiss and Hossain (2011) for analysing migration-health
relations during the entire migration process (these frameworks, as well as the
theoretical concepts, are described more fully in Chapter 2). The thesis
consequently analyses relations between migration and health in places of
origin, during travel, at the destination and after return. Moreover, the study
examines the situation and consequences for both migrants and family
members to migrants (“left-behinds”7), and for the relation between the two,
within the surrounding local and global context (I thus also follow the call by
Toyota, Yeoh & Nguyen, 2007, to bring the left-behinds into migration
studies). The study thus analyses migration-health relations from both an
individual and a broader structural perspective. By means of this approach, it
has been possible to place the study participants’ accounts of migration and
health into the wider context of local and global socio-economic and political
power relations that structure the migration processes under investigation in
this thesis (cf. Paerregaard 2008).
Health geography
Within geography, migration-health relations – as well as health and health
care in general – are primarily investigated within the sub-fields of medical
and health geography (for overviews of the research field, see Gatrell & Elliott
2009; Brown, McLafferty & Moon 2010; Anthamatten & Hazen 2011;
Schaerström, Rämgård & Löfman 2011). Medical geography draws inspiration
from the medical/epidemiological tradition as well as cultural ecology, and is
mainly concerned with the spatial patterning of disease, illness and medical
care (Mayer 2010; Rosenberg & Wilson 2005). Research within medical
geography that examines migration-health relations has consequently often
followed traditional epidemiological approaches that generally tend to focus
on the analysis of disease and illness among migrants in destination countries,
either at the time of their arrival or over time, in comparison with populations
in the host, or sending, countries (Gushulak & MacPherson 2006a,b).
Health geography – from which this thesis draws the most inspiration –
evolved in the late 1980s, in connection to the “cultural turn” in the social
the thesis, as they emphasize that migration is a process in which migrants interact and identify with multiple
nations, states and/or communities. See Chapter 2 for further discussion.
7 Although I use the term “left-behinds” I would like to stress that these persons, in general, are not passive
“victims” left behind by the “active” migrating family members (for example, passive recipients of the migrants’
remittances), but instead often actively involved in e.g. migration decisions (see e.g. Toyota, Yeoh & Nguyen,
2007) .
5
sciences when some medical geographers (most importantly Robin Kearns)
argued for a shift in focus within medical geography (for discussions on the
development of the field, see e.g. Kearns 1993; Rosenberg 1998; Kearns &
Moon 2002; Pearce 2003; Rosenberg & Wilson 2005; Moon 2009). Although
health geography is still closely related to medical geography – through the
shared interest in geographical variations in health and health care, for
instance – there are certain contrasts that are important to acknowledge in
order to understand where this thesis is positioned. As Robin Kearns called
for (for instance in his influential article from 1993), much of today’s research
in health geography is concerned with a holistic model of health, which
favours aspects of positive health and wellness (instead of mortality and
morbidity), as well as with a social model of health that acknowledges the
influence of economic, political, cultural and social factors on health.
Furthermore, health geography often takes a more critical stand towards
health issues, stressing aspects of inequalities/inequities in health, and the
importance of power relations in producing and reproducing these
differences. Following these advancements, this thesis critically analyses
migration-health relations in Nicaragua based on a holistic and social
understanding of health.
Within health geography, the key geographical concepts of place and space
have also gained a more prominent position, and the field is now characterized
by a “place awareness”. A relational view on place and space has consequently
been favoured, instead of the geometric space generally applied within
medical geography, concerned with distance and location (e.g. Rosenberg &
Wilson 2005; Moon 2009) (see Chapter 2 for further discussion on the
relational perspective). Through the new place awareness, health geography
now often stresses the importance of the local context, and of relations
between individuals and the local and the wider contexts, for understanding
health (Parr & Butler 1999). In line with the above, this thesis uses a relational
perspective on space and place, and thereby acknowledges the importance of
the relations between the individual and the surrounding social contexts for
understanding and analysing migration-health relations. One ambition of the
thesis is consequently also to “place” the migration-health nexus in the case
of Nicaragua in context.
Besides stressing “place awareness, a critical position, and an engagement
with sociocultural theory” (Moon 2009), health geography is also more
pluralistic than medical geography with regard to research methodology, and
includes not only qualitative and quantitative but also mixed-methods studies
(on qualitative approaches in health geography, see the special issue in The
Professional Geographer 1999, vol. 51, no. 2; see also e.g. Elliott & Gillie 1998;
and Dyck & Dossa 2007). In recent years, there have also been advancements
6
to incorporate ideas from the “mobilities” turn (e.g. Urry 2000, 2007) into the
field of health geography, with research on other types of mobility than
migration, such as travel/tourism, virtual mobility (e.g. mobilities of
information), and mobilities of care/carers (see for example Gatrell 2011). In
line with recent trends in health geography, this thesis uses a mixed-methods
approach to study the migration-health nexus, combining qualitative and
quantitative data materials. It also investigates health in relation to both
migration of a more permanent sort as well as to other types of mobility (e.g.
temporary migrant work).
The “Western” 8 bias in research on migration and health
Much of the international literature on migration and health has a Western
focus. This is clearly seen in the review by McKay, Macintyre and Ellaway
(2003), mentioned earlier, in which most studies had been conducted within
Europe, North America and Oceania9. Even though the studies often include
diverse immigrant groups – and are “global” in that sense – there are generally
fewer studies that take the South as its actual empirical base, and few are,
furthermore, published in academic journals in English. The research within
medical and health geography is also largely “an Anglo-American affair” (Parr
2004: 247) rather than a global issue. Much of the scientific debate and the
majority of research within the field has the English-speaking, Western world
as its audience, as well as its empirical base (see, e.g., Phillips & Rosenberg
2000; Kearns & Moon 2002; Jatrana, Graham & Boyle 2005; Hunter 2010).
Even though there is a range of quantitative studies conducted within medical
geography that also explore conditions in developing regions (in recent years
studies on HIV/AIDS, for instance) (Gushulak & MacPherson 2006a,b),
generally much less research has been done in Asia, Africa, and South
America. One consequence of this is that many research issues concerning
migration and health in Third World countries remain uninvestigated, or
poorly investigated due to limitations in data (Jatrana, Graham & Boyle 2005;
Konseiga et al. 2009; Adazu et al. 2009). Moreover, due to the diversity of
migration patterns and surrounding circumstances, previous results and
theoretical explanations from Western studies should naturally be explored
and validated in new settings (Hadley 2010; Gushulak & MacPherson
2006a,b). Hence, the knowledge about migration and health in Third World
countries is often sparse and fragmented, and there is still a need to conduct
8 The different terms I use for denominating regions and countries – e.g. “Western”/“North”/“Developed” and
“Third World”/“South”/“Developing” – are mere descriptive terms of global patterns of “development” (see e.g.
Potter et al. 2008; and Chant & McIlwaine 2009). “Development” is defined further on in the text.
9 McKay, Macintyre and Ellaway (2003) only mention one study from the Central American setting (Moss et
al. 1992). This indicates that a relatively small share of studies on migration and health have been done in the
region, and that those conducted often remain inaccessible to the English audience, or might not be digitalized.
7
empirical studies on migration and health in diverse socio-cultural
environments (Jatrana, Graham & Boyle 2005).
Previous research in the study setting
According to Cabieses et al. (2013), research on migration and health in the
Latin American context is limited, and much of it is also outdated. They
therefore conclude that “[t]here is an urgent need for better understanding of
the living conditions and health of migrant populations in Latin America”, and
that one area that specifically needs to be highlighted is the “the study of
migration as a dynamic and complex process inextricably connected with
broader economic, social, and international factors” (p. 72; my emphasis).
According to the authors, this would lead to stronger theoretical
understandings of the migration-health process, better data, and better
support for policy-makers in the region. This thesis consequently aims to
study the migration-health nexus in Nicaragua as a dynamic and complex
process connected to broader contextual factors.
According to my own review – which I make no claims is exhaustive – the
existing literature on migration and health in Latin America primarily
investigates nine different areas of study that in some way connect migration
and health, for example HIV/AIDS, mental health, mortality patterns, access
to and use of health care, remittances, and vulnerability. Most of the studies
focus on either migrants in South America, migrants of South American
descent, or Mexican migrants. Though some research has been done on
Nicaraguan migration patterns (migration within, from or to Nicaragua),
there are few published accounts of migration-health relations concerning
Nicaraguan migrants. The majority of the existing studies have used
qualitative research approaches (based on a limited number of participants),
and have mostly focused on emigrated Nicaraguans (primarily Nicaraguans
living in or travelling to Costa Rica). Additionally, they have tended to have a
particular health concern in focus (e.g. reproductive health or HIV/AIDS).
Furthermore, there are only a few unpublished reports and undergraduate
theses that have analysed migration data from the Nicaraguan Health and
Demographic Surveillance Systems (HDSS) (see below), on which this study
is partly based. All this points to a further need for more research on
migration-health relations in the Nicaraguan setting.
8
The migration-health nexus within the context of social
transformations and social inequalities
A complex dynamic of social transformations and social inequalities
surrounds the migration-health nexus, and serves as the foundation and point
of departure for this thesis’ investigation of migration-health relations in the
context of Nicaragua.
The migration patterns we observe in the world today – unquestionably a
pervasive feature of contemporary times10 – are part of globally encompassing
processes of economic, political, social, and cultural character, generally
termed processes of “globalization” (see e.g. Jensen & Tollefsen 2012;
Eriksson 2007; Potter et al. 2008; and Bauman 2000). Migration movements
both produce and are produced by these processes of global
interconnectedness, and take place in a context of vast socio-economic
inequalities and global and local power relations that influence people’s living
conditions and opportunities in life (see e.g. UNDP 2009). These processes
also have historical antecedents; therefore, I believe it is essential to
“historicise the present” (Mirza 2009: 6). I consequently discuss historical
developments with relevance for my research questions in the thesis (Chapter
4), in order to analyse how present migration-health processes are influenced
by practices in the past.
Several scholars also argue that migration should be understood and analysed
as part of broader (global) social transformations (see e.g. Castles 2010;
Davies 2007; Portes 2009). In relation to this the “migration-development
nexus” has received much attention, in both research (see e.g. Geiger & Pécaud
2013; de Haas 2012; Faist, Fauser & Kivisto 2011; Glick Schiller & Faist 2010)
and international forums (e.g. the United Nation’s [UN] High-level Dialogue
on International Migration and Development, and the Global Forum on
Migration and Development)11. Many different aspects of this nexus have been
investigated, and it has been viewed both optimistically and pessimistically
over the years. Research within the field stresses that migration and
“development”12 interrelate in manifold ways. One important research
10 The United Nations (UN) estimate the number of international migrants (i.e. persons moving across national
borders) at over 231 million, equalling about 3% of the world’s population (UN DESA, online database, accessed
2014-02-16). This is not even a third of all internal migrants (persons moving within countries); a number
estimated at 76o million in 2005, according to the UN (UN DESA 2013).
11 See: UN DESA, High-Level Dialogue on International Migration and Development, Internet (accessed 201401-07), and the Global Forum on Migration and Development (GFMD), Internet (accessed 2014-01-07).
12 “Development” – in the meaning human development – is a value-laden concept with many definitions. In
this thesis, I follow the UN’s definition which, in short, states that human development is about “the expansion
of people’s freedoms to live long, healthy and creative lives” (UNDP 2010: 2) (see Chapter 2 for further
discussion).
9
question concerns the interactions between levels of development and
migration patterns, and another fundamental question is, in brief, whether or
not migration is beneficial for development. Two issues with relevance for the
migration-health nexus are whether countries lose or gain human capital (e.g.
labour resources) due to migration (commonly discussed as “brain drain” and
“brain gain”, respectively), and whether remittances (the money migrant
workers send home to their family members) work as incitements for
development, and thereby may improve living conditions in the migrant
sending countries (see Chapter 2 for further discussion on migration and
development).
Health must also be placed in relation to socio-economic transformations (see
e.g. Kawachi & Wamala 2007; Gushulak & MacPherson 2006a,b; and Lee &
Collin 2005). Health is commonly regarded as key for achieving and
sustaining development13, and accordingly much research has been conducted
on the bi-directional interconnections between health and development over
the years (see, e.g., Ashtana 2009; Ruger 2003; Phillips & Verhasselt 1994).
One large research area focuses on the epidemiological transition, i.e. the
changes in health patterns said to take place in relation to socio-economic
development14 (McCracken 2009); and many studies investigate development
in relation to, for example, maternal and child health, communicable diseases
(such as HIV/AIDS), and health care systems/provision, as well as health in
relation to aspects such as poverty and structural adjustment policies (the last
of these areas will be discussed further in Chapter 2). Furthermore, since
diseases are no longer confined within national borders due to increasing
mobility and global communication, the character of disease, as well as its
treatment, has become global – indeed, “the body has been globalised”
(Turner 2004: 236). For example, a process of “medical globalization” has
taken place on a world scale since the 1950s, in which Western medicine has
come to dominate over indigenous forms of medicine (often referred to as
13 Health is an important aspect of human development, according to the UN’s definition (see Footnote 12).
Three of the Millennium Development Goals (MDG) – a set of goals adopted by the UN at the Millennium
Summit in 2000 in order to improve the living conditions for all inhabitants of the world – are in fact directly
aimed at improving health issues; i.e. child mortality (MDG4), maternal health (MDG5), and HIV/AIDS,
malaria and tuberculosis (MDG6) (see UN 2013). In the Millennium Declaration (see
http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/55/2), the UN also acknowledges that
globalization is key in the process, since its uneven effects, and costs, must change for an inclusive and equitable
world to be realized. See Pérez (2012) on the progress of MDG1 and 4 in León and Cuatro Santos, Nicaragua.
14 It is argued that the health patterns (health standards, disease burdens, mortality causes, etc.) of populations
change as societies develop. According to the original idea of epidemiological transition theory (cf. Omran 1971),
the burden of infectious diseases is said to be more common in developing countries, while chronic health
problems – so-called welfare diseases, e.g. cardiovascular diseases – are more common in developed countries
(McCracken 2009). Criticism of this theory has nevertheless been raised (see e.g. McCracken 2009), and today
there is evidence that developing countries experience a so-called “double burden” of disease, whereby the
population suffers from both infectious and chronic diseases simultaneously (see e.g. Agyei-Mensah & de-Graft
Aikins 2010, for the case of Ghana).
10
traditional medicine, or traditional medicinal knowledge, TMK). Problems
with over-use (of medicine and treatment) have occasionally been reported in
relation to this. Moreover, the “globalization of the body” has also produced
responses in policy and research regarding migrants. In this context,
migration has primarily been viewed in two ways – with focus on the threats
and risks it entails, or on migrants’ rights and entitlements to health and
health care. The tendency to regard migrants as potential disease-spreaders is
highly connected to what the anthropologist Mary Douglas (1966)
denominated “fear of pollution”, and what post-colonial scholars today
theorize as the “othering” of migrants and their “different” bodies (see e.g.
Ahmed 2000; Sandoval-García 2004). The rights-based approach to health
instead argues for health as a human right, and emphasizes entitlements to
health that are – or should be – equal for all human beings around the world,
including migrants. This “health-for-all” approach has its origins in the
Declaration of Alma-Ata from 1978, and the World Health Organization’s
(WHO) subsequent adoption of the “Health for all” strategy in 198115;
moreover, it was the foundation for WHO’s work with the Commission on
Social Determinants of Health (CSDH), whose final report from 2008
(CSDH/WHO 2008) clearly pointed out the vast inequalities in health that
exist both the global and the local level (that is, between countries/regions of
the world, and between different social groups within countries), which they
explain to a great extent with social factors16 (see also Pearce & Dorling 2009).
In sum, this thesis analyses migration-health relations in the case of
Nicaragua in the context of global socio-economic transformations,
particularly in relation to the debates on migration, development, and health.
The concept of mobile livelihoods is applied in order to emphasize how
migration, and consequently also migration-health relations, are embedded in
people’s strategies for making a living within the “globalized” labour market.
The role remittances play in people’s livelihoods – and whether they have any
possibility of improving living conditions, education, and health – is
scrutinized. Additionally, I look at what role health plays in migration
decisions, and in the development potentials of migration. Furthermore, the
thesis places the analysis of migration and health in Nicaragua in relation to
the globalization of the body, the right-based approach to health, and the view
15 The Declaration of Alma-Ata was adopted by the international community at the International Conference
on Primary Health Care in 1978 (see: http://www.who.int/publications/almaata_declaration_en.pdf).
Preparations before the conference were led by the Director-General of WHO, Halfdan Mahler. Mahler’s vision
of “Health for all by the year 2000” was adopted by the conference, and successively became the leitmotif of
WHO’s work (see also: http://www.who.int/social_determinants/resources/action_sd.pdf; and box 1.1, p. 6,
in http://apps.who.int/iris/bitstream/10665/85761/2/9789240690837_eng.pdf).
16 The Commission furthermore stressed that the widespread, global inequalities in health are avoidable, and
consequently a matter of social justice. Therefore, they preferably speak of inequities in health, i.e. inequalities
that are avoidable, unjust, or unfair (CSDH/WHO 2008).
11
of migrants as health threats, for example by investigating international
migrants’ health problems and access to health care, and by scrutinizing the
“othering” of Nicaraguan migrants.
Aim and research questions
The overall aim of this thesis is to critically explore and analyse relations
between migration and health, what I call the migration-health nexus, in the
contemporary Nicaraguan context. Based on a mixed-methods approach and
fieldwork in León and Cuatro Santos, Nicaragua, the thesis aims to provide
answers to the following research questions (chapter(s) in which a question is
primarily addressed in parentheses):
1) How can the dynamics between migration and health be understood in
the Nicaraguan context? (Chapters 4 and 5)
-
In what ways are Nicaraguan migration patterns and health trends
related to past and present socio-economic transformations?
How are these migration patterns and health trends related to
social differentiation (based on e.g. gender, ethnicity, class,
and immigration status)?
2) In what ways do health issues influence Nicaraguan men’s and
women’s migration strategies? (Chapter 5)
-
How are health concerns integrated into motives for
migration, staying and returning?
For what reasons are remittances sent, and how are
health issues related to these remittance patterns?
3) In what ways does migration affect men’s and women’s lives and health
situations in the different places and during the different phases
involved in the migration process? (Chapters 6 and 7)
-
How do different kinds of migration experiences affect the migrant,
(e.g. socially, economically, healthwise, and emotionally)?
-
How do different kinds of migration experiences affect the family
members of migrants (the “left-behinds”)?
12
Framing the study: the research collaboration, and the
Health and Demographic Surveillance Systems in León and
Cuatro Santos
This study was initiated within the framework of a long, ongoing research
collaboration between Umeå University in Sweden and León University
(UNAN-León) in Nicaragua17. As part of this collaboration, two Demographic
and Health Surveillance Systems (HDSS) were set up during the 1990s and
the 2000s; the first in the municipality of León, which is situated on the Pacific
Coast and harbours the second largest town in Nicaragua (León) (see Figure
1, p. x). The HDSS-León was initiated at the end of the 1990s, and is managed
by the Centre for Demographic and Health Research (CIDS). The second
surveillance site was initiated at the beginning of the 2000s in Cuatro
Santos18, an area in the northern part of Chinandega consisting of four
predominantly rural municipalities (San Pedro, San Francisco, Cinco Pinos
and Santo Tomás) (see Figure 1). The HDSS in Cuatro Santos is managed by
the organization CHICA19, in close collaboration with CIDS. Like other HDSS
sites20, the HDSS in León and Cuatro Santos regularly (often annually) gather
population-based data, with the ambition to monitor demographic processes
in the population, and to conduct epidemiological and public health research.
In Nicaragua, studies have been made on, for example, reproductive health
(Zelaya Blandón 1999), child health (Pérez 2012), intra-familiar violence
(Salazar Torres 2011; Ellsberg 2000; Valladares Cordoza 2005), and mental
health (Obando Medina 2011; Herrera Rodríguez 2006; Caldera Aburto
2004). (See Chapter 3 for a more detailed account of the contents of the HDSS
and how they developed).
The empirical material in this thesis, consisting of survey and interview data,
was gathered through fieldwork in the above-mentioned settings between the
years 2006 and 2008, with a follow-up visit in 2013 (see Chapter 3). The
quantitative part of the study (and to some extent the qualitative part as well)
was carried out within the frames of the two surveillance systems in León and
17 The Division of Epidemiology and Public Health Sciences at Umeå University played an important role in
the collaboration with UNAN-León, Nicaragua from the start in the 1980s, together with other departments at
Umeå University. The Department of Women’s and Children’s Health at Uppsala University was also an
important actor in the process. The largest funder of the research collaboration was the Swedish International
Development Cooperation Agency (SIDA).
18 Cuatro Santos is a figurative name for four municipalities in the department of Chinandega that all have
“San” or “Santo” in their names: San Pedro del Norte, San Francisco del Norte, San Juan de Cinco Pinos, and
Santo Tomás del Norte (in short: San Pedro, San Francisco, Cinco Pinos and Santo Tomás).
19 CHICA also coordinates and runs development projects in the area of Cuatro Santos.
20 There is a global network of HDSS sites, the INDEPTH Network, all situated in low- and middle-income
countries (the INDEPTH Network homepage, accessed 2013-04-26). At the time of the fieldwork the HDSS in
León was part of this network, but today it is no longer an INDEPTH site. The HDSS in Cuatro Santos has never
been a part of the network.
13
Cuatro Santos, in close collaboration with the organizations CIDS and CHICA.
This gave me access to a unique set of data on migration events, which is very
rare in low-income countries in the South. I also got to work in a research
environment with expertise on public health issues, and with many years of
experience conducting survey studies in the setting. Moreover, through
including both study settings I could explore the same issues in two rather
distinct places (e.g. rural and urban), which of course broadened the analytical
base. Nevertheless, there were of course also constraints involved with the
research approach, which will be discussed next.
Delimitations
Even though I had access to a unique set of data on migration events, a
limitation involved with conducting the study within the frames of the HDSS
in León and Cuatro Santos was that the study populations were pre-defined
and that data had been collected by others than myself over the years, which
meant that I had no control over previous work with sample selection and data
collection. Still, the HDSS are both well-designed and well-managed (see
Chapter 3). A perhaps greater limitation was that, even though the HDSS had
collected data on migration events for many years, the sizes of groups with
different migration characteristics within the populations – from which the
sample for this study was drawn – were sometimes small. Those categorized
as In-migrants (persons who had moved into the study areas) were
particularly few, and, in the analysis (i.e. the regression analysis), this group
proved to be too small to produce sound results. Another limitation involved
with using the HDSS was that persons who had moved out of the surveyed
areas (so-called “out-migrants”) could not be included in our survey, which
meant that I could only survey the out-migrants’ family members who still
resided in the HDSS areas. Moreover, people with illnesses, who were
identified in the first step of our survey, also numbered rather few for
particular migration categories (e.g. In-migrants and Left-behinds), even in
the León-setting. It was thus not possible to select the sample randomly, but
this was solved through selective sampling and applying appropriate weights
for each sample group in the statistical analysis. Furthermore, through
applying a mixed-methods approach, the quantitative study could also be
complemented with qualitative data, just as the qualitative study could be
enriched by the statistical information provided by the survey study. (See
Chapter 3 for further details on the methods applied).
14
Outline of the text
The next chapter in this introductory section provides the theoretical
framework that informs the analysis. The third chapter describes and
discusses the empirical material the study is buildt on, as well as the ways in
which it was gathered and analysed. The fourth chapter introduces the
contextual setting, Nicaragua and the two study settings León and Cuatro
Santos, in which the migration-health relations in this study are placed.
Thereafter follows the second part of the thesis, including three empirical
chapters presenting the findings of the study. Chapter 5 is dedicated to the
practice of mobile livelihoods and their relations to health, and presents for
instance health-related motivations for moving and staying. Chapter 6 is
concerned with the consequences of migration, and implications on health,
for the migrant. Chapter 7, the last empirical chapter, looks at the
consequences of migration on social relations, and thus focuses on the
relationships between migrants and left-behinds. Lastly, in the concluding
part of the thesis (Chapter 8), the findings of the study are summarized and
discussed in relation to the theoretical framework and previous research.
Mountain view, Cuatro Santos.
15
Alfombras – sawdust carpets with religious motives.
Easter 2007, Subtiava, León.
16
CHAPTER TWO
Theoretical framework
This chapter outlines the theoretical framework used in the thesis for
analysing the relations between migration and health in the Nicaraguan case.
The chapter first presents theoretical ideas and concepts concerning health
and migration, respectively, that I have made use of for analysing the
migration-health nexus. Thereafter follows an outline of some fundamental
understandings of this nexus, and a discussion of particular issues concerning
migration-health relations, such as migrant health, and transnational
families. The framework for analysing the migration-health nexus is
summarized at the end of the chapter.
Geographical and sociological perspectives on health
This thesis analyses health from a geographical and sociological perspective.
Both health geography and the sociology of health and illness are based on a
holistic (integrative), social and critical understanding of health (see below).
Health geography is also characterized by a “place awareness”, and gives
prominence to a relational view on space and place.
Putting health into place
Starting in the 1990s, a process of “putting health into place” occurred within
medical geography, which led to a reinvention of the discipline. This was a
highly necessary process, according to Kearns and Gesler (1998), since
“diseases, service delivery systems, and health policies are socially produced,
constructed, and transmitted” (ibid. p. 5; my emphasis). In the process of
putting health into place the unproblematic, geometric space generally
applied within medical geography – concerned with distance and location –
was criticized for conceiving space “as a mere blank surface on which [one]
uncritically [could] […] map medical and ‘deviant’ subjects” (Parr & Butler
1999: 11). The concept of place was subsequently more greatly acknowledged,
with the result that other spatialities, such as the body, received somewhat less
attention. Parr and Butler (1999) nevertheless highlight the importance of the
new place awareness: “[t]he retheorisation of place in medical geography as a
complex material, sociological, experiential and philosophical phenomena is
17
crucial to thinking through how the local is involved in the making of and
experience of different mind and body states (through place-based
understandings of health, illness and the body, as well as appreciating the
wider spaces of more structural contexts and responses to such phenomena)”
(ibid. p. 11).
According to the relational perspective on space and place, space is not seen
merely as a map surface on which places are located and things take place, or
as something “outside of place”, something “out there”, or “up there” (Massey
2005: 185). Instead, space is viewed as where the social is constructed, as the
product of social relations, as “our constitutive interrelatedness” (Massey
2005: 195). Put differently, space is the sum of the interactions and
interrelations between heterogeneous existences, or multiple trajectories,
which interrelate in a continuous and unending process (Massey 1994, 2005).
In the words of Doreen Massey (2005: 61), space is “the sphere of the
continuous production and reconfiguration of heterogeneity in all its forms –
diversity, subordination, conflicting interests”. Space thus also contains
material practices of power; the spatial may, hence, be seen as “a cartography
of power” (ibid. p. 85). From the relational perspective, places are,
furthermore, not regarded “as points or areas on maps, but as integrations of
space and time; as spatio-temporal events” (ibid. p. 130; italics in original).
Places are thus no more concrete, grounded or bounded than space is; nor are
they where “real life” goes on. Instead, places are open (thus connected to the
wider setting), and made up of a collection of all the spatial interrelations, as
well as the non-relations (the exclusions), that go on at a particular location,
at a particular point in time. Place is thus understood as “a moment within
power-geometries, as a particular constellation within the wider topographies
of space” (ibid. p. 131).
Relational thinking thus stresses how spaces and places emerge through
connections with other spaces and places on multiple scales, in contrast to
seeing spaces as static areas and places as fixed centres of meaning (Andrews
et al. 2012). Through applying the relational perspective on place and space
within health geography, the importance of the relations between individuals,
the local contexts and wider, structural contexts for health is thus emphasized
(Parr & Butler 1999). This view is foundational in this thesis, and has
influenced me to look at both migration and health, and the relations between
the two, from a relational perspective.
18
A holistic/integrative perspective on health
The holistic, or integrative, view of health stressed within health geography, is
also emphasized by the WHO, which defines health as “a state of complete
physical, mental and social well-being and not merely the absence of disease
or infirmity” (WHO 2006: 1). This definition has nonetheless been criticized
since coming into use in the 1940s, for example for its vagueness and
broadness (Callahan 2012). In my opinion it is still useful, since it shares
common ground with the “biopsychosocial”21 approach to health, which
extends the biomedical model of health that generally connects ill-health to
specific diseases and their pathological processes (White 2005). The
biopsychosocial approach stresses the importance of an integrated, or holistic,
approach to health and illness, and considers other factors than simply
biological processes for understanding health and illness, such as the social
context and psychological well-being (e.g. thoughts and emotions, which are
believed to be important both for health and for the ability to cope with illhealth and other difficult situations in life). Hence, the biopsychosocial
approach “incorporates thoughts, feelings, behavior, their social context, and
their interactions with both physiology and pathophysiology” (White 2005:
preface). Closely related to the biopsychosocial model of health is the concept
of “mind/body health”. Within mind/body medicine, the “Cartesian dualism”
– i.e. the doctrine that separated mind/soul and body – is questioned, and
instead the unity of the body is emphasized (Dreher 2004). The dynamics that
make physical and mental health influence each other are a central theme
within the field. An important study area, highly relevant in this thesis,
concerns the connections between stress and physical ill-health (see e.g.
Vitetta et al. 2005). Since migration is a well-known stressor (see further on
in the text), this research field is crucial in the analysis.
As health geography espouses a holistic understanding of health, it thus
favours other aspects of health than mortality and morbidity, such as positive
health and wellness (e.g. Rosenberg & Wilson 2005; Moon 2009). The holistic
view is also stressed within the sociology of health and illness. Within this field
health is seen as a complex phenomenon, composed not only of an objective,
pathological dimension, but also shaped by subjective and social factors (e.g.
social class, gender and ethnicity) (Wainright 2008). Health is furthermore
seen as influenced by processes on the micro, meso and macro levels. Hence,
the individual and his/her biological, cognitive, and emotional characteristics
are placed within the broader framework of social networks, social relations,
21 The “bio” (in biopsychosocial) stands for the biological, e.g. tissue changes; the “psycho” relates to the
psychological, e.g. personal growth and development; and the “social” concerns the social aspects, for example
a person’s current life situation (Shorter 2005; referred by White 2005).
19
social integration and social capital, the respective contents of which – for
example social ties and social support – all influence health. The meso and the
micro levels are in turn seen as influenced by relations at the macro level – the
social-structural conditions of society, for instance social and economic
inequality (Turner 2004). Based on these understandings, this thesis analyses
different aspects of health in relation to migration, and includes different
levels and scales in the analysis.
Social and critical perspectives on health
Both the biopsychosocial approach to health and mind/body medicine
acknowledge the importance of the social fabric for health (Dreher 2004); yet
it is within social medicine, public health and epidemiology that the most
extensive research has been conducted on the so-called social determinants of
health and illness – for example, the role material deprivation plays in shaping
health outcomes (see e.g. Turner 2004; Wainright 2008). The literature
shows, perhaps not surprisingly, that conditions such as poverty,
unemployment, low wages, inadequate housing, dangerous working
conditions, poor diet, insufficient sanitation, and poor environments have
negative effects on health22. Health geography also shares this social
understanding of health and thus acknowledges the importance of, for
example, economic, political, cultural and social factors for health. Moreover,
health geography also looks at health from a critical standpoint, stressing the
importance of power relations in producing and reproducing
inequalities/inequities in health (e.g. Rosenberg & Wilson 2005; Moon 2009).
The sociology of health and illness also emphasizes social and cultural factors
for health, and is tightly connected to the social determinant perspective on
health. The field also acknowledges that power relations, as inherent to all
social activities, also influences health outcomes; power is, thus, regarded as
“a key social-structural factor in health” (Freund, McGuire & Podhurst 2003:
x). Health, disease and illness are thus understood as not only related to
biophysical changes but also influenced and shaped by the wider socioeconomic context, power relations and social inequalities (Nettleton &
Gustafsson 2002). The emphasis the perspective of social determinants of
health places on the social fabric is very useful in this study, since for example
unemployment, low wages, and poverty in the study context of Nicaragua are
widespread and problematic (see Chapter 4). The critical perspective on
health, proposed by health geographers and sociologists, is also of importance
in the present study due to the inequalities in migration and health processes.
22 Consequently, the field stresses the necessity of social development and preventive medicine for
improvements in population health to be realized. This focus has been criticized, primarily for placing too much
emphasis on the structural forces of society and hence forgetting the individual’s role and responsibility in
shaping health outcomes.
20
The intersectional perspective emphasizes – in line with the above – the
importance of social differences, or stratifications, for understanding societal
processes (e.g. health). Gerry Veenstra (2013: 16) explains intersectionality as
a “framework for conceptualizing the nature of relations of power pertaining
to racism, sexism, classism and heterosexism in modern societies”.
Intersectionality is thus useful in understanding the complex nature of
inequalities – for example in health – in which power relations along the lines
of race, gender, class and sexuality, for instance, are intrinsically entwined.
Similarly, Nira Yuval-Davis (2006: 199) describes intersectionality as a
perspective on “differential positionings in terms of class, race and ethnicity,
gender and sexuality, ability, stage in the life cycle and other social divisions”,
which, when interlinked, “tend to create, in specific historical situations,
hierarchies of differential access to a variety of resources – economic, political
and cultural” (thus creating a “matrix of domination”, to use the words of Hill
Collins 2000; as referred in Veenstra 2013). Hence, when analysing health,
for example, according to the intersectional perspective it is necessary to look
at how different axes of inequality (in terms of, e.g., class, gender and
ethnicity/“race”) interact and create hierarchies that influence the individual’s
specific situation23. Immigration status (legal/irregular) may additionally be
added to the social differences of importance when analysing health in
relation to migration. The intersectional perspective provides a useful
analytical lens for examining inequalities in health in relation to migration in
the Nicaraguan case.
At the core of the perspective of social determinants of health also lies the
intrinsic dynamic between health and development (see Footnote 12 and
below for definition). Health is integral to development processes, and much
research has been conducted on the connections between the two over the
years (see, e.g., Ashtana 2009; Ruger 2003; Phillips & Verhasselt 1994). One
study area scrutinizes the health effects of the structural adjustment
programmes (SAPs) of the 1980s and 90s, which were imposed on many
developing countries (including Nicaragua) by the World Bank (WB) and the
International Monetary Fund (IMF) with the aim to stabilize the economies of
highly indebted countries through neo-liberal economic policies (see e.g.
Potter et al. 2008; Chant & McIlwaine 2009). The SAPs entailed massive
restructurings of the economies in many Third World countries, including
Nicaragua, with great implications on people’s living conditions. Studies have
shown that these programmes generally had profound consequences on the
health of the populations in these countries because of the cutbacks in social
23 As, for example, in Khan et al.’s (2007) study on health care experiences of patients from different ethnocultural groups in Canada, in which it was concluded that health and well-being were influenced by “the
complex issues at the intersections of gender, race, class, and culture” (ibid. p. 231), which the authors
furthermore argued were shaped by history.
21
spending, for example in the health care sector (e.g. Ashtana 2009; Ruger
2003; Phillips & Verhasselt 1994; and Wainright 2008). Even though changes
have been made to improve the programmes, and some countries have
cancelled parts of their debt (e.g. Nicaragua; see Chapter 4), the effects of
structural adjustments still linger. Many Third World countries will, for
example, probably not realize the health-related UN Millennium
Development Goals (MDG) (see Footnote 13), partly as a result of these
cutbacks in public services (Wainright 2008; see also Vargas 2006, in relation
to Nicaragua)24. Another example of relations between health and
development concerns “medical globalization”. This process began during a
period when modernization theories25 flourished. The faith in “modern”
medicine for eradicating diseases (such as smallpox) in developing countries
was great at this point in time, and Western (occidental) medicine and health
care were consequently spread globally, and people were often encouraged to
use the products of modernity. Consequently, in many parts of the world today
Western medicine is dominant over indigenous forms of medicine (traditional
medicine, TMK), and it is also occasionally over-used (Turner 2004;
Wainright 2008). The relation between health and development is at centre
stage in the case of Nicaragua; for example, in relation to the health effects of
the structural adjustment programmes, and the progress towards meeting the
Millennium Development Goals. Nicaragua has also been affected by the
process of medical globalization.
Social capital and social citizenship
The idea of “social capital”, and its relation to health, has received much
attention in research26. One definition understands social capital as “the social
investments of individuals in society in terms of their membership in formal
and informal groups, networks, and institutions” (Turner 2004: 13). Social
capital theory is relevant in this thesis, since it regards social relations as
24 WHO’s work with the Commission on Social Determinants of Health (CSDH), mentioned in Chapter 1, is a
good example of how the social determinant perspective is integral in the work to achieve human development.
As mentioned, the Commission stressed the role of social factors in health (CSDH/WHO 2008; see also Pearce
& Dorling 2009).
25 The perspective usually referred to as Modernization Theory (or Modernism) was largely based on the
European experience of development, and influenced by evolutionary and diffusionist theory, arguing that
development is “a positive and irreversible process through which all societies eventually pass” (Chant &
McIlwaine 2009: 27). Development was thus regarded by some as “all about transforming ‘traditional’ countries
into modern, westernized nations” (Potter et al. 2008: 5; italics in original).
26 Different meanings have been assigned to the concept of social capital over the years, by scholars in various
academic disciplines. It was first used within economics to explain the importance of economic investments in
education, training and welfare, in order to produce human capital (Turner 2004). In sociology, the concept
originates from Émile Durkheim who, at the end of the 19th century, found that rapid social changes and social
disruption caused negative effects on health (i.e. higher levels of suicide) (1966 [1897]). Later, James Coleman
(e.g. 1988) and Robert Putnam (e.g. 1993, 2000) made important contributions to the concept’s further
development (Turner 2004).
22
fundamental to health, and because it highlights specific aspects of the social
fabric that are especially important for health (social integration and social
inclusion, which according to the theory are created through people’s social
investments, i.e. social ties and social support). Moreover, social capital theory
has also provided new insight into the research on inequality and health.
According to Richard Wilkinson (see e.g. Wilkinson 1996; and Wilkinson &
Pickett, 2009), more egalitarian societies have higher levels of social cohesion,
lower levels of social disruption and lower levels of individual stress, which
result in better health and longer, more satisfying lives for their citizens. Other
scholars similarly argue that income inequality leads to low trust in society,
which negatively affects the social environment (social cohesion), and in turn
also individual health (Turner 2004, with reference to Kawachi et al. 1999;
Antonucci et al. 2003). More critical voices (e.g. Coburn 2000, 2004) argue
that the cause behind income and health inequalities is neo-liberalism, as
social inequality has increased and social cohesion has decreased during the
neo-liberal era27. Coburn’s idea is interesting because it relates people’s
subjective experiences of health and illness to macro changes in the political
environment. In this thesis, the theoretical idea of social capital has provided
an operationalization of particular social aspects (e.g. social ties and support)
that may influence migration-health relations.
Social capital theory thus proposes that social relations are crucial for health.
However, health is also determined by power structures within society, and is
consequently related to the access to and control over society’s resources (such
as material, cultural, and social resources) (Turner 2004). The concept of
“social citizenship” has been developed in relation to this, concerning the
rights and entitlements citizens enjoy – either because they have earned it (for
example through work or other social activities) or because governments
acknowledge that they have needs which could be satisfied collectively (Turner
2004). The social rights of citizenship are important in order to overcome
disparities in health. In welfare states, such as Sweden, health is often
regarded as a social right; this is why individual health standards in such
countries are often high, and the differences in health between individuals
small, according to Turner (ibid.). In Turner’s words (2004: 8), “health can be
27 According to Coburn, the nation-state has lost its authoritarian position due to neo-liberalism, with the result
that social inequality has increased and social cohesion has decreased, leading to lower levels of social trust and
self-esteem, as well as a lack of social support – in short, diminishing social capital – which affects health
negatively. Some scholars, e.g. Wilkinson (2000), have nevertheless criticized Coburn; while others, e.g. Tarlov
(2000), find his argument plausible. In line with this, contemporary social capital theory proposes that rapid
social and economic changes – such as the fall of Communism, civil wars and ethnic conflicts, the globalization
of the world economy, and neo-conservative economic policies – have produced social isolation and social
disorganisation, resulting in poor health (increasing morbidity and mortality) in many societies around the
globe. In this way, labour migration from south to north caused by unregulated global economic markets can
be understood as causing social disintegration, and possibly also affecting health standards negatively (Turner
2004).
23
seen as the unintended consequence of the social rights of citizenship, and not
necessarily an intended outcome of medical interventions”. There is evidence
that higher levels of social cohesion lead to more egalitarian patterns of
political participation, which in turn are associated with a better provision of
health services and distribution of medical information to the public (Turner
2004, with reference to Berkman & Kawachi 2000). The concept of social
citizenship, and its importance for health, is relevant in the context of this
study, where people’s access to resources is highly uneven (see Chapter 4). The
analysis of health issues in the case of Nicaragua must consequently be related
to these inequalities.
Embodiment, emotions and health
In order to fully understand how the relation between the social (society) and
health is played out, theories on the body, “embodiment”, and emotions are
also central in this thesis. As Nettleton and Watson (1998: 1) write:
“Everything we do, we do with our bodies […]. Every aspect of our lives is
therefore embodied”. This field thus argues that people’s experiences are
embedded within the body – basically, “the human being is an embodied
social agent” (ibid. p. 9). Embodiment, thus, also has a spatial dimension. In
the words of philosopher/sociologist Henri Lefebvre (1991: 162), “it is by
means of the body that space is perceived, lived – and produced”. It is thus
through our bodies that we perceive, assess, adapt and design space
(Kenworthy Teather 1999); in other words, it is through our bodies that we
live our lives, have relations with other people, find our way and experience
the world. The concept of embodiment takes the idea of the relation between
the social and health a step further than other social perspectives on health.
The embodiment of people’s experiences (of the social) might then perhaps
explain more profoundly why, for example, social isolation and income
inequality cause ill-health – the experience of it (isolation, inequality) is
embodied, that is, “brought into” the body, and thereby affects health.
The unity of body and mind that is integral to the idea of embodiment is also
stressed by emotion sociologists28 (see e.g. James & Gabe 1996; Williams &
Bendelow 1996; Lupton 1998; and Barbalet 2002). However, through
including emotions (i.e. mental states, strong feelings) it is possible to explore
even more deeply how embodiment “works” in practice, and how social
structures in reality affect people’s health. According to Deborah Lupton
(1998), emotions are essential in how people experience their body,
28 Emotions have made a rather late entry into geographical research, and the field of emotional geographies
has mostly focused on the phenomenology of emotion, i.e. the experiential aspect of emotional phenomena (e.g.
emotional responses and attachments to particular places) (Smith et al. 2009; Davidson, Bondi & Smith 2005;
and Anderson & Smith 2001). Therefore, I rely more on sociological research on emotions in this thesis.
24
subjectivity, and relationships with others, and are therefore central in
understanding embodiment. Emotions can be conceptualized in different
ways29. Social psychologist Parrott (2001) proposes a complex system of
human emotions, all believed to stem from a few primary emotions (love, joy,
surprise, anger, sadness, and fear). In this thesis, I have used Parrott’s
classification to analyse the emotions the interviewees expressed during our
talks. I believe this to be necessary since our emotions – both those we feel “in
reality” and those we express to others – may influence our health, as well as
our ability to cope with difficulties in life (see below).
Since emotions are naturally embodied, it can be argued that emotions and
emotional experiences are the most powerful factors determining health,
regardless of whether the explanation is seen as biological, cultural or social
(Williams & Bendelow 1996). Due to this, emotion sociologists argue that
emotions should be regarded as the mediator – the “glue” – between micro
and macro relations; between the individual body and the social structure; for,
as Williams and Bendelow (1996: 46) write, “the body is in the mind, society
is in the body, and the body is in society”. Emotions are thus central in
understanding the dynamic between society, the body, and health. Instead of
simply acknowledging that social structures – e.g. social relations, social
support, and social status – affect health (as for instance social psychologists
or health sociologists do), emotion sociologists state that emotions are key in
this process, and thereby more profoundly explain how social structures can
actually affect people’s health. There is in fact a bulk of predominantly
psychological and social psychological research that explores the relations
between emotions and health, for example between emotions, stress and
health (for an overview see Folkman 2011; see also, e.g., Part VII in Lewis,
Haviland-Jones & Feldman Barrett 2008; Pennebaker 1995; Lazarus 2006),
and there is evidence that positive emotions are often better for one’s health
than negative ones (see Chapter 6 in Greco & Stenner 2008). Another relevant
concept in this thesis is “suffering”, as it was commonly expressed by the
interviewees as well as by Nicaraguans in general who I came across during
the fieldwork. Suffering not only embraces “negative” emotional experiences,
for example sadness, anxiety and distress (Wilkinson 2005), but also refers to
many other aspects (physical, psychological, social, economic, political, and
cultural) and is thus a holistic concept that can be said to capture “the
vulnerability of lived experience” (Wilkinson 2005, with reference to Turner
& Rojak 2001). Moreover, entire populations can also experience social
29 There are many theoretical views on human emotions (for an overview, see Lewis, Haviland-Jones &
Feldman Barrett 2008), and throughout the years scholars have also presented several different
conceptualizations of emotions (see, e.g., Turner 2007). Paul Ekman (e.g. 1999, 1992a,b) has proposed a
conceptualization of six basic emotions (anger, disgust, fear, sadness, happiness and surprise), which he argues
are general to all human beings, and which he has characterized as either positive or negative.
25
suffering, for example when a nation is under collective stress due to extensive
migration (Helman 2007).
Stress, health and coping
The relations between stress, health and coping are other important issues in
this thesis. Stress, that is, demands that require behavioural changes – for
example life events (e.g. migration), chronic strains (e.g. poverty), and daily
hassles (e.g. traffic) (Thoits 1995, 2010) – may have many negative health
effects (see e.g. Williams et al. 2003; Weiss & Lonnquist 2000; Helman 2007).
Stress furthermore stimulates “coping” processes (Thoits 1995); coping thus
takes place when the individual makes the appraisal that something relevant
to him or her is being harmed or threatened, or has been lost, in a situation
that feels difficult to handle (Folkman & Moskowitz 2004; Lazarus & Folkman
1984; Antonovsky 1979). Individuals’ capabilities to cope vary depending on
their access to “coping resources” (for example, self-esteem, social support,
and sense of control or “mastery over life”; see Thoist 1995, 2010; cf.
Antonovsky 1979) – and the employed “coping strategies” (attempts to
manage the situation) (Thoits 1995). The coping resource “social support”
(including, e.g., emotional support) can be important for health, since it
functions as a “social fund” to draw from when handling stressors (ibid.).
Research shows that coping strategies can be more or less beneficial for
health. There is also evidence that religion plays an important role in the stress
process (Folkman & Moskowitz 2004). The understanding of the connections
between coping and psychological, physiological and behavioural outcomes is
still not clear, in part because of the complexities surrounding stress
processes.
The framework of stress and coping is relevant in this thesis, as both
Nicaragua’s
socio-economic
conditions
(in
terms
of
massive
underemployment and poverty) and migration patterns indicate that many
may be living under stress, which may set off coping processes and produce
health effects. In the thesis I have also investigated various types of social
support (for example, perceived and received emotional and economic
support) in the analysis of migration-health relations, which is also why this
theoretical foundation is important.
Health care
The model of medical care applied in a country generally has a large impact
on the provision and utilization of health care services. Two common models
are the collectivist/public model, which aims for universal access to health
26
care, and is structured around the principle of need rather than the ability to
pay, and the anti-collectivist/private model, which gives precedence to the
market and is funded by private health insurance, or by fees paid by the user
at the point of use (Gatrell & Elliott 2009). The localization of health care
services, and people’s distance to them, are important issues in relation to the
access to and use of health services. The question of distance as a constraint
to people’s utilization patterns has indeed received a great deal of attention in
research; there is evidence of a clear “distance decay” relationship between
physical distance to health services and health-seeking behaviour, meaning
that people living farther from health services seek health care more seldom
(Gatrell & Elliott 2009). The reasons behind this may be time-space
constraints, and costs in terms of time and travel, that deter people from
seeking care. However, it is not only physical distance that is important for
people’s use of health care; social and cultural factors are also important – for
example, affordability (that is, being able to afford the costs, not only of travel
but also of the health care itself), cultural barriers (e.g. appropriateness,
language), and social marginalization (e.g. of the homeless) (ibid; see also
Curtis 2004). A distance decay effect also seems to exist in developing
countries (e.g. Muller et al. 1998, referred to by Gatrell & Elliott 2009; and
Feikin et al. 2009, referred to by Anthamatten & Hazen 2011). Yet, a more
important question in these regions is perhaps whether there is an adequate
overall level of health care delivery at all, particularly primary care, and that
this care is not only geographically concentrated to urban areas (Gatrell &
Elliott 2009).
However, health care is not only about provision, access and use; it is an
integral part of society, and thus a political, economic and cultural concern
(Conradson 2005). The question of who cares for whom therefore largely
reflects power relations in society. The analysis of health care thus also
concerns issues of gender, ethnicity/“race” and class (e.g. Lawson 2007). For
example, the greatest burden of caring is often shouldered by women and by
immigrant groups (particularly immigrant women), and care work is often
devalued. Furthermore, as health care is often characterized by inequalities
(as mentioned above), it is also a question of social justice. Neo-liberal
economic policies and restructuring (e.g. in the form of structural adjustment
programmes) have led to a more privatized health care sector in many
countries (as mentioned), causing greater social inequalities in the access to
care (e.g. Lawson 2007).
The issue of health care is central in this thesis, since it has great implications
on people’s possibilities to reach and afford care. The health care situation in
Nicaragua will therefore be described in Chapter 4.
27
A social transformation and relational perspective on
migration30
As mentioned in the introduction, this study analyses health in relation to
both moves within the borders of Nicaragua, and moves between Nicaragua
and other countries. The thesis consequently requires a theoretical framework
that includes theories on both internal and international migration – of which
there is a wide range (see overview in Boyle, Halfacree & Robinson 1998; and
for international migration see Castles, de Haas & Miller 2013). However, as
several scholars point out the need to integrate migration theory with social
theory, I understand migration as part of social transformations and
development processes, and therefore apply the concept of “mobile
livelihoods”31 (Olwig & Sørensen 2002) in the thesis, as a way to conceptualize
migration in relation to people’s possibilities and efforts to make a living.
Moreover, as recent migration theory points out that contemporary migration
patterns often entail many different kinds of moves, encompass different
phases, and link different places and peoples in the process, I make use of
theoretical ideas and concepts that highlight the processual and relational
nature of migration; most importantly, “translocal geographies” (Brickell &
Datta 2011), “transnationalism” (e.g. Vertovec 2009), and “transnational
social space” (Faist 2000).
Migration, social transformations and development processes
This thesis applies a social transformation perspective on migration, which
integrates migration theory and social theory in the analysis (see e.g. Castles
2010; Davies 2007; Portes 2009; and de Haas 2010). Migration is seen in this
thesis as interlinked to global socio-economic transformations (see e.g.
Castles 2010; Davies 2007; Portes 2009) – or, “globalizing” processes (see e.g.
30 Following Boyle, Halfacree and Robinson (1998: 34), migration is defined in the thesis as “the movement of
a person (a migrant) between two places for a certain period of time” (italics in original). Migration is often also
defined spatially (as movement across internal or international boundaries), temporally (as more or less
permanent moves), and according to motivation (as more or less voluntary moves) (ibid.). These distinctions
between, for example, temporary and permanent migration are not so clear-cut in reality. They may, however,
be useful for analytical purposes, as King (2002, 2012) points out. In this thesis, both internal and international
moves, of both permanent and temporary character, are regarded as “migration”.
31 Since this thesis focuses on “migration” but uses a concept including the term “mobility” (i.e. mobile
livelihoods), the terminology needs some further explanation. Migration, according to Boyle, Halfacree and
Robinson (1998), should be distinguished from mobility, which “embraces all forms of geographical
movement” (ibid.; my emphasis), ranging from e.g. international moves, changes of domicile within the same
residential area, and shopping trips (see Åkerlund 2013 for a detailed discussion of the concept of mobility).
Scholars within the “mobilities paradigm” (e.g. Urry 2000, 2007) sometimes argue that migration should also
be seen as a subset of spatial mobility, but as King (2012) points out, this has its disadvantages. For example,
attention can be diverted from the embodied experience and “groundedness” of migration, as well as from the
unequal power relations that influence border control regimes. Based on this, I generally use the term
“migration” in this study, and mostly make use of literature within migration studies. The concept of mobile
livelihoods is an exception to this, since I find it useful for integrating migration and livelihood studies.
28
Jensen & Tollefsen 2012; Eriksson 2007; Potter et al. 2008; and Bauman
2000) – which are characterized by large social differences (see e.g. UNDP
2009, 2013). More concretely, the transformationalist perspective emphasizes
“how a variety of conditions and parallel processes combine to bring about
large-scale patterns of transformation”, which produce “broader – indeed,
global – enduring, structural shifts in social, political and economic
organization” (Vertovec 2009: 21, 23; following Held et al. 1999). Thieme
(2008: 55) argues that migration – for many, but certainly not for all – should
be regarded as “a necessary and enforced strategy to adapt to economic
globalisation”. One pertinent example of the embeddedness of migration in
socio-economic transformations concerns the structural adjustment
programmes (SAPs) (see above), which have indirectly shaped migration
patterns in many countries (see Davies 2007). Because of their magnitude,
social transformations differ slightly from more general development
processes that usually take place in only one locality or on one level or scale
(Vertovec 2009). Still, social transformations naturally influence local
conditions (e.g. the level of development in a particular place), at the same
time as the local commonly affects the global. Hence, social transformations
may be described as global-local processes, or as a dialectic relationship in
which the local and the global are constantly co-constructing one another32
(Massey 2005). This global-local relationship is, furthermore, framed by
macro- and micro-level power relations; hence, there exists a “power
geometry of time-space compression” (Massey 1994) in which people and
social groups are placed (see also McDowell 1999).
Development processes are nevertheless important in the thesis, especially
with regard to their dynamics with migration and health. Development is a
value-laden concept with many meanings. Long regarded as synonymous to
economic growth, the term has successively come to include social and
political values. In general, development entails changes; preferably – but not
always – in terms of improvements in people’s lives, or in societies at large
(for longer discussions on the concept, see Chant & McIlwaine 2009; and
Potter et al. 2008). In this thesis I follow the United Nations’ (UN) view, which
implies that human development is a dynamic concept that concerns initiating
and sustaining positive outcomes (changes) over time, as well as eradicating
structural injustices that impoverish or oppress people (see, e.g., UNDP
2010). Based on ideas primarily stemming from the work of Amartya Sen (e.g.
Sen 2000), according to the UN development also concerns personal freedom
and choice. In short, human development may thus be defined as “the
expansion of people’s freedoms to live long, healthy and creative lives” (UNDP
32 This dialectic relationship is what the term “glocalization” tries to capture (see e.g. Robertson 1995; Bauman
1998).
29
2010: 2). Based on this view of development, the UN has developed the
Human Development Index (HDI) through which the level of development in
all countries of the world is measured every year (UNDP 2013). The index, a
summary measure of human development ranging from 0-1, measures the
average achievements in a country in three basic, but crucial, dimensions of
human development: (i) a long and healthy life (i.e. life expectancy at birth),
(ii) access to knowledge (i.e. mean years and expected years of schooling), and
(iii) a decent standard of living (i.e. GNI per capita)33. The HDI makes it
possible to follow a country’s development in different indicators over time
(see Chapter 4 for the HDI development in Nicaragua).
Migration and development interrelate in manifold ways; yet, despite
extensive research on the migration-development nexus – for example, the
prospect of “brain drain” in countries with a high number of high-educated
emigrants, or the effect of remittances on local development – the results and
conclusions are varied, and there are still no clear-cut answers to the overall
question of whether migration is beneficial for human development (see e.g.
Faist, Fauser & Kivisto 2011; Glick Schiller & Faist 2010). One reason for this
is that the effects of migration often “[depend] upon who is migrating, where
they are moving from and to, how they move, what they do after they move,
and the political, economic, social and cultural contexts in which the
movement occurs” (Raghuram 2009: 107). Hence, paraphrasing Raghuram
(2009), “context is critical” when analysing the migration-development
nexus. Indeed, migration does not take place in a social, cultural, political or
institutional void (as implied in neo-classicist economic migration theory) (de
Haas 2010), which makes the surrounding spatio-temporal context utterly
important when analysing the potential developmental effects of migration.
Portes (2009: 18) provides a useful typology in which he highlights the
importance of the type of migration for its developmental effects – whether it
is skilled or unskilled, cyclical or permanent migration. I would suggest adding
the factor of immigration status to Portes’ typology, since the fact of having or
not having the legal right to stay in another country may have substantial
implications, both on the migrant’s experience in the new country and on
33 Life expectancy at birth refers to the number of years an infant is expected to live at birth if prevailing
mortality rates continue. Mean years and expected years of schooling are the average number of years of
education received by people older than 25 years, and the number of years of schooling a child can expect to
receive if prevailing enrolment rates continue. GNI per capita refers to Gross National Income (GNI) per capita
(PPP US$) (i.e. the aggregate national income converted to international dollars and divided by midyear
population). The indicators for the second and third dimensions of the HDI have varied since the first Human
Development Report (HDR) was published in 1990 (due to refinements in methodology). Previous reports used
“adult literacy rate” and “combined gross enrolment in school” (except for the years 1991-94 when “adult
literacy” and “mean years of schooling” were used, and 1990 when only “adult literacy” was used), and instead
of GNI per capita, GDP (Gross Domestic Product) per capita was used (UNDP 2011, 2013, 2014). For further
information on how the HDI is calculated, see the Human Development Report 2013, Technical notes, available
online: http://hdr.undp.org/sites/default/files/hdr_2013_en_technotes.pdf.
30
his/her possibilities to work, send remittances, and have contact with the
origin. Raghuram and Portes thus point to the need to contextualize and
differentiate the migration-development nexus. Even though the results from
the field are inconsistent, one might however argue that for the people
involved in the process, remittances may be an important – and sometimes
crucial – source of income, and also possibly lead to enhancements in life.
Moreover, “brain-drain” effects are possibly less salient today, with migration
patterns increasingly characterized by transnationality and circularity (so that
ties are maintained between origin and destination countries) (de Haas 2005).
Mobile livelihoods
In order to further connect migration to social theory but still relate it to social
transformations and development processes, I make use of the concept of
“mobile livelihoods” (Olwig & Sørensen 2002; see also Briones 2009 for an
application of the concept in a study on Filipina domestic workers in Paris)34.
Olwig & Sørensen (2002:9) conceptualize mobile livelihoods as “the various
practices involved in ‘making a living’, as well as the social relations used to
make a living possible, in the different contexts where they take place” – either
close-by or far away, within the same state or locality, and/or in another
nation35. Using mobile livelihoods is thus a way to conceptualize migration in
relation to the practice of livelihoods. Livelihood approaches generally seek to
empower “poor” people, by viewing them as active agents in trying to improve
their livelihoods within the (often) constraining surrounding conditions (de
Haas 2010). “Livelihoods” may, furthermore, be defined as the “capabilities,
assets (material and social resources), and activities required for a means of
living” (de Haas 2010: 244, with reference to Carney 1998; see also Chambers
& Conway 1991, referred to by Helgesson 2006). The concept thus embraces
three main aspects that are necessary for making a living: (i) capabilities, i.e.
personal characteristics and abilities to cope with stress and shocks, and to
find livelihood opportunities and pursue them; (ii) assets, including various
types of “capital”, i.e. human capital (labour resources within the household),
social capital (social networks, access to institutions), financial capital
(savings, remittances, pensions), natural capital (land, water), and physical
capital (transportation, housing, equipment); and (iii) the activities
undertaken within the household to make a living (Helgesson 2006, based on
34 Susan Thieme (2008) also proposes the linking of (transnational) migration theories and livelihood studies,
as a way to connect migration studies to social theory and show its embeddedness in people’s livelihoods (as
does Jonathan Rigg, see e.g. Rigg 2007). Thieme proposes the concept of “multi-local livelihoods” to capture
the importance of migration in people’s livelihoods (thus similar to the concept of mobile livelihoods).
35 Depending on the context, different theoretical perspectives can be used in the analysis; for example, a local,
translocal or transnational perspective. I apply the translocal and transnational perspectives in this study, as
explained further on in the text.
31
Rakodi 2002; see also de Haas 2010, with reference to Carney 1998). Taken
together, these capabilities, assets and activities form so-called “livelihood
strategies”, which can be defined as “a strategic or deliberate choice of a
combination of activities by households and their individual members to
maintain, secure, and improve their livelihoods” (de Haas 2010: 244)36.
According to Hein de Haas (2010), migration is increasingly recognized as an
important livelihood activity (yet, he emphasizes that migration is generally
not the only livelihood strategy in a household but is instead often combined
with other multi-local or multi-sectoral household activities). In his words,
migration is “one of the main elements of the strategies households employ to
diversify, secure, and, potentially, durably improve, their livelihoods” (ibid. p.
244) (even though de Haas’ argument is mainly based on evidence from ruralurban migration, he argues that it can also be applied to international
migration). Remittances are seen as part of a household’s livelihood strategies.
The household perspective promoted in livelihood approaches is useful, as it
situates the individual migrant’s actions in relation to the broader social
context, which is especially relevant in studies on migration in Third World
countries, where individuals often act on behalf of the family (Bauer &
Zimmermann 1998, in de Haas 2010)37. Nevertheless, a sole focus on the
household or the family may be problematic, since individuals often also have
social bonds with persons other than household members (de Haas 2010).
Furthermore, it is important to acknowledge that power relations also exist
within families or households, based on for instance age and gender, which
may create inequalities and have implications on the decision-making
concerning livelihood strategies). Susan Thieme (2008) argues, in fact, that
both migration and livelihood studies have tended to be “blind to inequalities
and unequal power relations in the migration process, as well as to the social
and cultural differences between societies and the resulting respective (and
conflicting) networks of migrants” (Thieme 2008: 57). More recent
approaches to migration therefore emphasize the need to analyse power
relations and inequalities in migration processes, especially when the research
focuses on households or families (see e.g. de Haas 2010).
36 Livelihood strategies are also usually shaped or constrained by surrounding factors, such as policies,
institutions, infrastructure and service, vulnerability context, and external environment (Helgesson 2006,
based on Rakodi 2002). Nevertheless, even under constrained circumstances, people – even “poor” people –
have the possibility to develop and pursue strategies. As Helgesson (2006: 18) states “[g]iven the horizon of
possibilities and the space of constraints, one could argue that each actor has a space of action” (with reference
to Long 2001; italics in original).
37 The focus on families and households is shared with the New Economics of Labour Migration (NELM) (cf.
Stark 1978, 1991), which perceives migration as a household risk-spreading strategy, and at the same time a
strategy for overcoming market constraints (thus an extension of earlier, neo-classical theory, which exclusively
interpreted migration as an “optimal allocation of production factors” [de Haas 2010: 230]). Moreover, the
NELM considers remittances to be of central importance in migration processes, even as a fundamental reason
for migrating, and crucial for providing the household with money to possibly improve the household economy
(de Haas 2010, 2012).
32
Translocal geographies and transnational social spaces
In the thesis I also make use of other conceptualizations of migration that
stress its processual and relational nature. The concept of “translocal
geographies” (Brickell & Datta 2011) builds on previous relational migration
perspectives, most importantly the “transnational” perspective, which sees
migration as a process in which migrants interact and identify with multiple
nations, states and/or communities, rather than as a static act consisting of
moves from one country to another without further contact between origin
and destination (see, e.g., Glick Schiller, Basch & Blanc-Szanton 1992; Portes,
Guarnizo & Landolt 1999; Faist 2000; Levitt & Glick Schiller 2004; Tollefsen
& Lindgren 2006; Vertovec 2009; Glick Schiller & Faist 2010), as well as the
idea of “translocality”, which emphasizes local-local connections as a way to
situate “deterritorialized notions of transnationalism” (Brickell & Datta 2011:
3). The concept of translocal geographies extends the transnational and
translocality frameworks by emphasizing how spaces and places are both
situated in and connected to a variety of locales – e.g. local, regional, national,
and international – without giving preference to any particular situatedness
(such as the nation in previous perspectives). It thus provides a framework for
analysing the geographies of everyday lives across spaces, places and scales;
and hence, for analysing “the overlapping place-time(s) in migrants’ everyday
lives” (ibid. p. 4), including different types of movements – be it internal or
international migration, or other types of mobility and non-mobility.
The transnational perspective is still an important theoretical foundation in
the thesis, particularly in the analysis of health in relation to international
migration. Scholars who use the concept of transnationalism often (but not
always) complicate the acts of migration, through critically asking who
migrates, and under what circumstances (see e.g. Marchand 2009; Grewal &
Kaplan 2001). This critical approach is important to also keep in mind in the
process of trying to understand health in relation to Nicaraguan migration
processes, for instance by asking: who is moving? where to? under what
circumstances? and with what effects? A central idea within the transnational
perspective is that of “transnational social space”, which Faist (2000: 199)
defines as “combinations of sustained social and symbolic ties, their contents,
positions in networks and organizations, and networks of organizations that
can be found in multiple states”. Primarily three forms of transnational social
spaces exist, according to Faist: transnational kinship groups (multi-local
households, e.g. transnational families), transnational circuits (trading
networks, e.g. Lebanese businesspeople), and transnational communities
(diasporic groups, e.g. the Jewish diaspora). Transnational kinship groups will
be discussed further in the empirical part (see Chapter 7).
33
Even though I use a translocal and transnational perspective on migration in
the thesis – which emphasizes cross-border movements and contact – I would
like to stress that borders, particularly international borders between one
independent nation and another, still have a role to play in today’s “mobile”
world, and that border thinking is still fundamental to the human experience
(see, e.g., Khosravi 2011; Yuval-Davis & Stoetzler 2002; Newman 2003; Silvey
2006). The concept of borders is therefore also important, and will
consequently be discussed in the thesis (see Chapter 6).
The interrelations between migration and health
This section will first point out some basic understandings of migration-health
relations that are fundamental in the thesis, and thereafter discuss certain
themes of migration-health relations of particular importance to the thesis
subject. After this section, the chapter closes with a re-capitulation of the
theoretical framework used in the thesis.
The migration-health nexus as a bi-directional process
The migration-health nexus is commonly viewed in the literature as a bidirectional process in which migration and health may affect one another
(Jatrana, Graham & Boyle 2005, with reference to Hull 1979; Gatrell & Elliott
2009). This thesis therefore analyses the various effects of migration on
health, and the various effects of health on migration. As migration is
understood as a relational process here, health is scrutinized in relation to the
whole process of migration, including the different actors, spaces, places, and
scales it involves. I therefore make use of the frameworks for analysing
migration-health relations developed by Haour-Knipe (2013) and
Zimmerman, Kiss and Hossain (2011). In these frameworks, migration is seen
as encompassing several different places and phases, which the authors argue
should be included in analyses of migration and health: (i) the origin (predeparture phase); (ii) the transit (travel phase); (iii) the destination
(reception, interception and integration phases); and (iv) the origin (return
phase). In the thesis, health is thus “traced” within the migration process.
Consequently, the study analyses migration-health relations from both the
individual and the broader structural perspective (relations at the micro,
meso, and macro levels). On the individual scale the focus has been on, for
example, health problems (physical and mental). On the relational scale,
attention has been paid to social relations and social networks, for example.
Lastly, on the structural scale the focus has been on aspects such as national
politics and global institutions.
34
The “globalized” body
As mentioned previously, a globalization of the body has taken place in
relation to the “globalizing” world (Turner 2004). Accordingly, much
attention has been given to, for example, the “risk society” and global
regulations. Concern has also been raised in the field of public health, for
instance regarding the challenges population mobility imposes on nationstates’ health systems and health policies (see e.g. MacPherson & Gushulak
2001). In this context, migration has persistently been viewed as a threat to
public health; a view dating back to medieval times when measures to control
the spread of communicable disease were common, and perhaps sometimes
necessary. A more rights-based approach towards migration and health has
gained footing in recent years, in connection with the research and policy field
of global health. In relation to this field, a discussion has arisen concerning
health as a human right –for migrants as well. These views will be discussed
next.
The tendency to regard migrants as potential disease-spreaders is highly
connected to what the anthropologist Mary Douglas (1966) called “fear of
pollution”. Douglas argued that an important mechanism for preserving social
structure is to distinguish “purity” from “impurity” or “polluting” elements (in
the context of this study, for example, to preserve national sovereignty by
distinguishing foreigners from nationals). Following Douglas’ reasoning,
migrants can be seen as “polluted” and “polluting” (Khosravi 2011; Malkii
1995). Similarly, today’s post-colonial theory theorizes the “othering” of
migrants. This theory provides a useful outlook, through “making visible the
process by which concepts such as ethnicity, race and culture have been
constructed and used to create binaries locating non-European peoples as the
essentialized, inferior, subordinate Other” (Khan et al. 2007: 230). For
example, writing about “stranger danger” (i.e. fear of “others”), Sarah Ahmed
(2000) says that “[b]y defining ‘us’ against any-body who is a stranger, what
is concealed is that some-bodies are already recognised as stranger and more
dangerous than other bodies” (pp. 3-4). In the process of self-definition, of
identification, the stranger (the “other”) is consequently ousted as the origin
of danger. Hence, the stranger is “an effect of processes of inclusion and
exclusion, or incorporation and expulsion, that constitute the boundaries of
bodies and communities” (Ahmed 2000: 6). Consequently, the “stranger
danger” discourse discussed by Ahmed may, for example, lead to societies
characterized by hostile relations to immigrants. Sandoval-García (2004)
writes about these processes in relation to Nicaraguan migration to Costa Rica
(see Chapter 6).
35
In contrast to the view of migrants as a health threat, the rights-based
approach stresses the health implications for individual migrants, and the
challenges health care systems face to provide services to all (Thomas &
Gideon 2013; Zimmerman, Kiss & Hossain 2011). The proceedings from the
Seminar on Health and Migration, organized in 2004 by the International
Organization for Migration (IOM) and WHO (amongst others), clearly
demonstrate that the rights-based approach has largely been adopted by the
international community, but also that the view of migration as a threat to
public health is still viable today38. The idea of a transnational, or flexible,
citizenship has been introduced in relation to this, through which citizen
rights – usually tied to the nation-state – are instead seen as tied to the
individual, wherever he or she should travel or settle down (Turner 2004, with
reference to Bauböck 1994, and Ong 1999). Turner (2004) emphasizes the
need for a “medical citizenship”, which would ensure all humans’ right to
health, regardless of national citizenship or residence. In Turner’s (2004: 269)
words: “the right to health cannot be detached from more general questions
of social equality and security. […] Health is an outcome of a complex web of
rights that attempt to address issues of justice in a world where such questions
can find only global solutions”. Women’s health rights have been particularly
highlighted in this discussion, as women often suffer the most from poverty
and inequality, and are also often exposed to more vulnerability as migrants
(e.g. as sex workers, refugees or labour migrants) (Turner 2004).
This thesis analyses the migration-health nexus in the case of Nicaragua as
part of the discourses and research on both migrant health rights and
migrants as a health treat. Paricularly relevant are the issues of the “othering”
of migrants (including experiences of vulnerability and precariousness) and
migrants’ access to health care, and the effects these have on migrant health.
Migrant health
This section will discuss aspects of migrant health that I have found to be
particularly relevant for analysing the study’s empirical material – migrant
work, vulnerability and precariousness, stress, discrimination and racism, and
access to health care.
38 As seen in the issues discussed at the meeting: national migration policies, pre-departure health screenings,
the mental health of migrants, the migration of health care workers, health care for undocumented migrants,
policy reform, and investments in migration health; as well as in the meeting’s concluding statements, which
state for example that there is a “need for a global approach to public health management, the creation of
comprehensive policies capable of servicing all migrant populations, and partnerships in migration health”
(IOM 2005: 10).
36
The issue of migrant work is highly relevant in this thesis, since contemporary
Nicaraguan migrations are primarily connected to people’s strategies for
making a living. Consequently, many Nicaraguans have experiences of
migrant work, often characterized by unequal, racialized and gendered work
relations, which may affect health diversely. Through work, the body is
intimately connected to larger socio-economic relations, often characterized
by unequal power relations in today’s complex, “globalized”, and polarized
labour markets (Wolkowitz 2006). Bonacich et al. (2008: 342) argue that the
division of labour within today’s global capitalist system is “a hierarchically
organized, racialised labour system that differentially exploits workers based
upon their gendered and racialised location”. Similarly, María Lugones
(2007), discussing “the coloniality of power” (cf. Quijano 2000), states that
the division of labour under “global, Eurocentered, capitalist power” is
“racialised as well as geographically differentiated” (Lugones 2007: 191).
Furthermore, the social position of migrant workers is also determined by
these processes (Weiss 2005). Care work provides a good example of the
gendered, international division of labour. Scholars argue that global
inequalities are a precondition for functioning “body work”39 in the North,
since a large part of the labour power it involves consists of immigrants or
migrant workers (Wolkowitz 2006). The concept of “transnationalization of
reproductive labour” (e.g. Ehrenreich & Hochschild 2002; for an overview, see
also Wolkowitz 2006) has been developed in relation to this, illuminating the
process whereby migrant women from poorer countries leave their families
and children to take care of the reproductive work (child-rearing and
household work) in richer families in richer countries (see also Lutz 2002).
“Global care chains” also evolve in this process, through the
commercialization of care and love (e.g. Hochschild 2000; for an overview see
also Yeates 2012). These care chains also exist on a societal level, since
immigrants and migrant workers represent a large part of the labour force
within public health care in many richer societies40. The work performed by
migrants in other sectors of the labour markets in richer societies, such as
agriculture and industry, can also be seen in this light (Wolkowitz 2006).
Thus, health may be profoundly affected by work relations; in terms of both
what type of work is performed and the social relations and social structures
surrounding the work process. The large-scale changes in the structure of
labour markets41 indicate that work should also be analysed in connection to
39 “Body work” concerns work involving the body, such as beauty care, physical exercise, health care, child
care and housekeeping (Wolkowitz 2006).
40 This is said to potentially lead to the “brain drain” of the Third-World countries from which the care
workers originate.
41 For example, the global shift in manufactural production from developed to developing countries, and the
post-industrial, service-oriented economy, including new forms of work and employment.
37
the social aspects of society. The theoretization on work, the understanding of
today’s global labour markets as increasingly unequal, racialized and
gendered, as well as its relation to health, is highly relevant in this thesis, since
many study participants had migrated for economic reasons. Furthermore,
the concepts of transnationalization of reproductive labour and global care
chains are applicable, since many Nicaraguan women work as nannies and
maids in Costa Rica.
The concepts of “vulnerability” and “precariousness” are important in relation
to migrant work and health. Vulnerability is a broad concept referring to, for
example, people’s vulnerability in the face of large-scale changes (e.g. climate
change, natural disasters, economic decline), and social aspects (e.g.
vulnerability within households). At the core of the concept lies the exposure
to shocks or strains, and experiences of suffering (Pendall et al. 2012); thus
one definition relates it to humans’ exposure to psychological damage, and the
propensity to suffer morally and spiritually (rather than physically) (Turner
2004). Wolkowitz (2006) argues that a “structure of vulnerability” (cf. Nichol
1997) has arisen globally, due to the more insecure and difficult working
conditions in the world today. Moreover, illegal border crossings often put
migrants in a particularly vulnerable situation, especially females, who are
often subject to sexualized violence during the border crossing (Khosravi
2011; Falcón 2007; Ruiz Marrujo 2009). Besides difficult strains and
sufferings, migrants also face death during the journey (see e.g. Slack &
Whiteford 2011). Especially relevant in this thesis is the Mexico-US border,
where many migrants – including Nicaraguans – die every year (Eschbach et
al. 1999, 2001; Sapkota et al. 2006; Holmes 2013; Guerette 2007). The
literature points to a relation between increased border security and migrant
fatalities (e.g. Eschbach et al. 2003; Cornelius 2001; Orraca Romano & Corona
Villavicencio 2014), partly due to a redistribution of migratory flows (a “funnel
effect”) into more remote and dangerous areas. Moreover, the enforced border
politics also lead to more difficulty travelling back and forth, thus resulting in
the migrant’s “entrapment” inside the US.
Precariousness refers above all to the insecure working conditions we see
throughout the world today. Guy Standing (2014) argues that the large-scale
changes in labour relations, patterns of work, and systems of social protection,
regulation and redistribution that have taken place under neo-liberal global
capitalism have created a new class structure in which the “precariat” is a new,
lower class. Migrant workers are in a particular vulnerable and precarious
situation, for they are over-represented in precarious jobs (“dirty” and lowpaid jobs, such as cleaning and agriculture) (e.g. Wolkowitz 2006). Moreover,
it can be argued that migrant workers suffer a “double” precariousness,
38
particularly if they have irregular status42. Goldring and Landolt (2011)
discuss how precarious work and precarious legal status (e.g. irregularity)
intersect, and argue that migrant workers’ insecurity and vulnerability stem
not only from irregularity, but also from the migrants’ social positions
(ethnicity/“race”, gender and class). There is research that points to the
negative health effects of precariousness (e.g. Tompa et al. 2007; Brabant &
Raynault 2012).
Both concepts, vulnerability and precariousness, are central in this thesis.
Through vulnerability, the exposure to risks and suffering in relation to the
migration process can be highlighted and better understood; and, through
precariousness, the dimension of insecurity in relation to work (“precarious
work”) can be added to the analysis.
In light of the above, it is evident that migration can be a stressful experience.
The act of moving to a new country perhaps entails the most stress,
particularly if the move is conducted without documents. Still, closer moves
can also have stressing effects. In fact, all kinds of migration generally entail
dislocation and disruption – not only spatially, but also socially, culturally,
and environmentally – which may be experienced as stressful (e.g. Gatrell and
Elliott 2009). The processes of “estrangement” (Ahmed 2000) and “cultural
bereavement” (Helman 2007; with reference to Eisenbruch 1988) may cause
stress in the individual migrant, in relation to being in a new place. Another
potential source of stress among migrants is the reception at the destination,
often characterized by xenophobia, racism and discrimination (Gatrell &
Elliott 2009), which may cause negative health effects (e.g. Williams et al.
2003; Paradies 2006). However, there is still uncertainty regarding the
relation between racism and stress (for example, whether racism is distinct
from other types of stressors), which points to the need for further
investigation (Paradies 2006). The issue of migration and stress is important
in this thesis, for analysing the health impacts of migration. The concepts of
estrangement and bereavement are used to illustrate the emotional side of
migration stress, and discrimination and racism are used to discuss both the
direct and indirect implications it may have on the health of migrants.
In the literature, the issue of migrants’ access to health care is discussed
primarily in relation to international migrants. Hargreaves and Friedland
(2013) (with certain focus on European conditions) state that existing studies
show that immigrants – even though they may be entitled to health care –
often face certain barriers in accessing it, which influence service use and may
42 There are certainly other types of migrants besides migrant workers who are in a precarious situation, for
example refugees, sex workers and victims of trafficking or smuggling, whose particular vulnerabilities have
been highlighted in recent literature (see e.g. Van Liempt & Bilger 2009).
39
explain patterns of ill-health. Socio-economic position and immigration
status, together with discrimination and a lack of understanding of the health
care system, seem to cause the most important constraints to migrant’s access
to health care (Cabieses & Tunstall 2013; Gideon 2013; Gatrell & Elliott 2009).
In relation to internal migration, one may argue that rural-urban migrants, in
general, improve their access to health care due to the urban bias in
localization of services. The issue of migrants’ access to health care, and the
barriers constraining this access, is important in this study, in relation to both
internal and international migration. As regards internal migration, the
question of better access in the cities is especially important; and concerning
international migration, the question of entitlements and discrimination is of
particular importance, especially for the undocumented migrants in the study.
Transnational families and health
In relation to the increasingly transnational and circular patterns of migration
described earlier in the thesis, and the resulting changes in family relations,
there has been an upsurge in literature on “transnational families”. The issue
of transnational families is important in this thesis for understanding the
implications of transnational – as well as translocal – migration on family life,
and the effects these implications may have on health and caregiving.
“Transnational parenthood” (transnational mothering and fathering) and
“transnational caregiving” are particularly important for analysing the effects
of family separation, and the ways in which transnational family life is coped
with.
“Transnational families” are a particular type of families, characterized by the
fact that the family members “continue to feel they ‘belong’ to a family even
though they may not see each other or be physically co-present often or for
extended periods of time” (Baldassar & Merla 2013: 6). Despite being
separated over time and space, transnational families thus maintain a sense
of “family-hood” (Bryceson and Vuorela 2002; quoted in Baldassar & Merla
2013). In order to sustain this family-hood, transnational families employ
different strategies, including, for example, “negotiating a plan for family or
kin to care for children upon the parent or parents’ departure and until their
return, ensuring that economic remittances are sent to support family wellbeing, and using phone calls, letters and video to stay involved in each other’s
lives” (Schmalzbauer 2008: 334).
One central aspect in the research on transnational families is familial
separation. Research shows that separation from family may induce great
stress, affect the emotional well-being, and sometimes even cause depression,
40
for both migrants and their family members who remain in the country of
origin (e.g. Aguilera-Guzman et al. 2004; Aroian & Norris 2003; Espin 1987,
1999; referred in Silver 2011). In relation to children who are separated from
their parents, Suárez‐Orozco, Todorova and Louie (2002) write that the
literature points to a negative experience for the children, both during the time
when their parents are gone and when/if reunification takes place. According
to Silver (2011), one important reason for this is that migration involves a
strain on the support networks of both migrants and their family members,
sometimes even leading to the breakdown of social support. This might cause
stress in the individual since social support, particularly stemming from close
relationships (e.g. spousal and parent-child relations), is an important buffer
against mental distress, as mentioned earlier (see also Thoits 1995, 2010).
Another, closely aligned reason for the health effects of separation is that the
family undergoes fundamental transformations in relation to transnational
migration. New familiar relations, new roles, and additional responsibilities,
for example, need to be adapted to, and these changes may be an important
source of stress for both the migrant and the family members left behind (e.g.
Silver 2011; Schmalzbauer 2004; Pribilsky 2004). The issue of parenthood has
consequently received much attention in the literature, since parent-child
relations are fundamentally changed in cases of parents migrating and
children being left behind at the origin (see e.g. Carling, Menjívar &
Schmalzbauer 2012). A new form of “transnational parenthood” has arisen, in
which “the parent-child relationship is practised and experienced within the
constraints of physical separation” (ibid. p. 193). As parenting roles are
commonly gendered (performed in different ways by men and women),
transnational parenthood is also “affected in gender-specific ways” (ibid. p.
192), both for the mothers and fathers who stay and for those who migrate.
Even though both migrating mothers and fathers perform similar
transnational parenting activities – for example, sending money and gifts, and
maintaining communication – many studies show that greater expectations
often are placed on mothers who migrate, and that migrating mothers
continue to be responsible for the emotional care of children (see e.g. Parreñas
2000, 2001, 2002, 2005; and Hondagneu-Sotelo & Avila 1997). A
predicament of transnational motherhood is therefore that the act of
“mothering” is performed from afar, which may be a difficult and stressful
experience (ibid.). Transnational fathers and “fathering” have not received as
much attention in the literature as have transnational mothers and mothering
(Parreñas 2008), probably because the father’s absence through migration is
more consistent with traditional gender norms (e.g. male breadwinning) and
therefore does not reconstitute the gender behaviour in the family.
The separation within transnational families can lead to other stressful
experiences as well. Differences in access to resources and decision-making
41
between family members may arise, for example, which can cause stress for
both the migrant and the family members left behind (Silver 2011). The
difficulties separation entails are perhaps felt even more when migration is
undertaken irregularly, since it might lead to entrapment in the destination
country, as mentioned earlier (see Khosravi 2011; Menjívar 2012). However,
the separation within transnational families naturally does not always cause
emotional pain or stress. Some may experience the separation as providing
new opportunities, independence and empowerment (e.g. Silver 2011).
Transnational families are greatly sustained by the exchange of “transnational
caregiving” (Baldassar & Merla 2013), a particular form of care and support
that is reciprocal yet uneven: “[t]ransnational caregiving, just like caregiving
in all families (whether separated by migration or not), binds members
together in intergenerational networks of reciprocity and obligation, love and
trust, that are simultaneously fraught with tension, context and relations of
unequal power” (Baldassar & Merla 2013: 7). The idea of transnational care
circulation extends previous conceptualizations of global care chains, and
highlights “how care circulates around a wide network of friends and family,
crisscrossing both local and national settings” (ibid. p. 12).
In this thesis the conceptualizations concerning transnational families are
important in the analysis of translocal family life and the effects separation
may have on health.
Recapitulation: a critical framework for analysing the
migration-health nexus
In this thesis I emphasize the need to place Nicaraguan migration processes
in relation to relevant globalizing processes in modern times, for example the
“globalized” labour market, and the period of structural adjustments that also
fundamentally affected Nicaraguan society. The analysis of migration-health
relations also needs to be situated in relation to development processes, and
how they interact with global social transformations and their inherent power
relations. Additionally, the question of whether migration is positive or
negative for development – including that of people’s health – needs
contextualizing and differentiation in order to grasp the interrelations and
effects. In order to analyse migration-health relations in the case of Nicaragua,
I make use of the frameworks elaborated by Haour-Knipe (2013) and
Zimmerman, Kiss and Hossain (2011), which state that migration-health
relations should be analysed within the whole process of migration. I
consequently scrutinize the entire process of migration in order to “track” the
42
bi-directional connections between migration and health, including the
different actors, spaces, places, and scales this involves.
I use the concept of mobile livelihoods as it highlights the embeddedness of
migration in people’s lives and livelihoods, of which remittances are one
important aspect. Moreover, the concepts of translocal geographies,
transnationalism, and transnational social spaces are used in the thesis as they
highlight the processual and relational nature of migration. The concept of
translocal geographies is especially applicable in the analysis, as it emphasizes
relations across different spaces, places and scales (thus, both internal and
international migrations can be analysed within this framework). By use of the
transnational perspective, cross-border relationships, ties, and networks, as
well as inherent inequalities and mechanisms of in/exclusion from global
migration processes, can also be analysed, as can the connections of migration
to social transformations. Conceptualizations of borders are furthermore
applied in the thesis since they shed light on inherent asymmetries in
migration processes.
An integrative/holistic view of health is applied in the thesis, based on the
biopsychosocial model of health, and the concept of mind/body health. These
perspectives imply that health is composed of a combination of biological,
psychological and social factors, and that physical and mental health are
tightly connected. The social perspective (e.g. the social determinants of
health) further stresses that health is shaped by social factors (e.g. social class,
gender and ethnicity), and also that power relations – which are inherent to
all social activities – also influence health outcomes. Social factors and power
relations have therefore been taken into account in the analysis of migrationhealth relations; for instance, through the use of the concept of “social
citizenship”, which highlights the importance of access to society’s resources
for health, and the entitlements citizens have to, for example, health care
services. The dynamic between health and development is also crucial in the
analysis since, for example, the issues of medical globalization, structural
adjustment programmes, and the Millennium Development Goals are at
centre stage in Nicaragua. The idea of social capital is, furthermore, used in
the thesis in order to operationalize particular aspects of the social fabric that
may influence migration-health relations (e.g. social relations, social support,
and reciprocal exchanges of help/remittances). Moreover, the concept of
embodiement is used in the thesis as a way to more deeply elaborate on the
connections between the social and health. Additionally, emotions are
analysed, based on theories on the relations between emotions and health,
stress and coping.
43
The findings of the study are put in relation to the issues of migrant health
rights and the “othering” of migrants. The sociological theoretization on work,
and its relation to health, is used in the thesis for analysing migrant work in
the context of unequal, racialized, global work relations, and their effects on
health. The concepts of transnationalization of reproductive labour and global
care chains are used in relation to this for analysing the particular situation
for female migrant workers in care sectors. Moreover, I apply the concepts of
vulnerability and precariousness to discuss the exposure to risks and suffering
during the migration process, as well as insecure work conditions.
Additionally, literature on the stresses of migration – most importantly
discrimination, racism and health – is used for discussing the health impacts
of migration. The issue of migrants’ access to health care is also central in the
thesis, in relation to both internal and international migration. Lastly,
research on transnational families, transnational parenthood, and
transnational caregiving is applied in the analysis of transnational – as well as
translocal – migration, and the effects these processes may have on family life,
health and care. Moreover, it is a firm understanding that social differences,
power relations and inequalities shape the relations between migration and
health under scrutiny in this thesis, in which questions of ethnicity/“race”,
class, gender, and legal status play a crucial part.
The next chapter will discuss the empirical material the study is based on, as
well as the methods used to analyse it. The last chapter in Part I, Chapter 4,
will thereafter provide a background to the context of the study – Nicaragua,
and the two study settings of León and Cuatro Santos.
“Welcome to San Franscisco del Norte”, Cuatro Santos.
44
CHAPTER THREE
Materials and methods
A mixed-methods case study
This thesis builds on a case study of migration-health relations in Nicaragua.
The study combines qualitative and quantitative research strategies in order
to shed light on both the deeper and the general picture of migration-health
relations, and thereby explore the case to the fullest. The empirical material,
including qualitative interview data and survey data, was gathered through
fieldwork in two settings in Nicaragua: the town of León, situated in the Pacific
coast area, and the area of Cuatro Santos, consisting of four predominantly
rural municipalities in the northern part of Chinandega (see map on p. x).
This chapter starts with an introduction to case study methodology, followed
by a critical discussion of mixed-methods research. Then, the fieldwork and
the qualitative and quantitative studies are presented in detail, including the
study’s empirical material and the methods used for analysing it. Lastly, some
reflections on the use of mixed methods as well as its advantages and
disadvantages are provided at the end of the chapter.
Case study methodology
“By whatever methods, we choose to study the case.” (Stake 2003: 134)
As Stake (2003) asserts, case study research is not a choice of a particular data
collection method but rather of what is to be studied. Therefore, case studies
may use qualitative or quantitative research methods, or a mix of both – as I
have done in this study. Common to all case studies is that they focus on one,
or a few, specific and unique case(s) in depth in the study of complex
phenomena (Tollefsen Altamirano 2000). Therefore, when applying case
study methodology in research, the definition (selection) of the case is of
major importance. In this thesis, the main case under investigation is
migration-health relations in Nicaragua. The two study settings, León and
Cuatro Santos, can be regarded as “cases within the case” (Stake 2003: 153),
as can the interviewees and survey respondents who participated in the study.
Another important aspect when using case study methodology regards the
type of case study being conducted. While some aim only at describing and
45
analysing the particularity of a case – intrinsic case studies – others also aim
at portraying what the particular case may say about other cases (i.e. to
generalize) – instrumental case studies. A number of cases may also be
studied with the ambition to say something about other situations – collective
case studies (Stake 2003). This thesis shares many similarities with collective
case studies, since the decision was made to conduct the study of migrationhealth relations with a large number of participants (the survey study), aiming
at generalizing the findings to the greater Nicaraguan population. However,
there are also elements of the intrinsic case study, as I made a good deal of
choices concerning who would participate based on, for example, where they
lived. Moreover, I also found the particular case under study interesting and
important in its own right, which also means that my approach shares
elements with the intrinsic case study.
Case study research shares similarities with the holistic tradition, which
emphasizes the importance of taking into consideration “the whole”43 in
research (Bubandt & Otto 2010). As a methodological tool, the holistic
tradition places great weight on open-mindedness (including as many factors
of importance as possible) and comprehensiveness (including the
surrounding context of the phenomenon under study in the analysis) in order
to grasp the totality of the whole (Bubandt & Otto 2010)44. Although the task
of grasping the totality of a complex whole may be impossible (if a
phenomenon can be regarded as a “whole” to begin with), I find the idea
inspiring. I have therefore taken a comprehensive grip on migration-health
relations in this study and, with an open mind, have tried to include as many
relevant aspects as possible. The study therefore scrutinizes both physical and
43 A “whole” culture, society, region or system, for example. The idea of “wholeness” was foundational in the
“classic” era of geography – primarily in the works of von Humbolt and Ritter, who in different ways tried to
understand the whole complex system of the universe, and emphasized the unity of nature and humanity; and
subsequently in regional geography (e.g. Vidal de la Blache), which regarded regions as complexes of natural
and cultural phenomena in unity (Holt-Jensen 2009). Holism as a concept is used more seldom in human
geography today – as a result of the specialization of geography, and perhaps also due to the shift to relative
and relational views of space – yet, the idea of holistic inquiry is still up for discussion (see e.g. Ley & Samuels
2014 on humanistic geography, and Trudgill & Roy 2014 on physical geography). Sui and DeLyser (2012) even
argue that a “holistic turn” has taken place in geography in recent decades, which they exemplify by the calls for
a unified geography, and the mixing of qualitative and quantitative methods. In anthropology, holism has a
more prominent position (Otto & Bubandt 2010) and is primarily derived from structural functionalism, which
assumed social phenomena to create a whole. Even after post-modern and post-structural criticism the concept
still lingers in anthropology, albeit in new forms. Today, holism can be regarded as “a comprehensive approach
to the human condition” (Bubandt & Otto 2010: 3).
44 Complexity theory also builds partly on the holistic tradition focusing on system’s complex behaviour – for
example, the behaviour of ecosystems or transport networks in terms of relations and networks (e.g.
interconnectedness and non-linear interactions) (Gatrell 2005). Complexity theory thus shares similarities with
system-based approaches in general, and with network theories specifically, but according to Gatrell (2005) its
notions of emergence and hybridity add value, as does the focus on exploratory research. Scholars in health
geography have recently advocated the use of complexity theory in order to enhance the understanding of the
complex relations that influence health, which can seldom be reduced to, for example, linear models of
individual behaviour such as logistic regressions (Gatrell 2005; see also Curtis & Riva 2010).
46
mental health in relation to the whole process of migration, including the
effects of health on migration and the effects of migration on health, for both
migrants and family members of migrants (left-behinds). Moreover, I analyse
a variety of aspects, on different spatial scales, that may be of importance for
migration-health interactions. Additionally, I provide a rather “thick”
description of the contextual landscape for the case of Nicaragua (Chapter 4),
since I believe – in accordance with case study and holistic methodology – that
it is necessary to recognize that the migration-health relations under scrutiny
do not take place in a vacuum but rather in economic, political, social and
cultural environments (with inherent relations of power), which act as
prerequisites for these interrelations.
Mixed-methods research
The mixed-methods research approach (MM), which I have employed in this
study, “combines elements of qualitative and quantitative research
approaches (e.g. use of qualitative and quantitative viewpoints, data
collection, analysis, inference techniques) for the broad purposes of breadth
and depth of understanding and corroboration” (Johnson, Onwuegbuzie &
Turner 2007: 123). By use of MM, information in both narrative and
numerical forms concerning a research issue can be provided; for example,
qualitative data can be used to add meaning to quantitative data, and
quantitative data can contribute to the generalization of qualitative data. The
research problem is often more at centre stage in MM than the methods per
se, which instead are often seen as mere tools for answering the research
questions. The integration of approaches usually takes place throughout the
research process: in study design, data collection, analysis and presentation
(Hesse-Biber 2010).
The use of mixed methods as a research approach has gradually become more
common in the social sciences. The first study to explicitly talk of mixing
methods stems from the mid-1950s (Campbell & Fiske 1959; in Teddlie &
Tashakkori 2009), but MM as a research approach in its own right –
distinguished from qualitative and quantitative research methods – did not
develop until the 1990s/2000s (for more details on the history of mixedmethods research, see Johnson, Onwuegbuzie & Turner 2007; and Teddlie &
Tashakkori 2009). The health and nursing sciences have produced many
mixed-methods studies since the 1990s (e.g. Cohen et al. 1994, and Bryant et
al. 2000, in Teddlie & Tashakkori 2009; see also e.g. Stewart et al. 2008).
Within geography, at the end of the 1990s population geographers and
migration scholars pointed out the need to employ mixed methods in order to
move migration research forward (see e.g. Findlay & Li 1999; McKendrick
47
1999; and Lawson & Silvey 1999; for a recent geographic study combining
qualitative and quantitative methods, see Hjälm 2011)45. The mixed-methods
research approach did not enter health geography until the 2000s (see e.g.
Crooks et al. 2011); however, according to Kearns and Collins (2010) it is
gradually becoming more common (but there were still very few MM studies
in 2012, at least at the annual meeting of geographers in Canada; see
Giesbrecht et al. 2014). Still, scholars continue to make further calls for it, for
instance in relation to the advocacy of complexity theory (see Footnote 44).
Curtis and Riva (2010: 220), for example, argue that “the counterproductive
dualism between ‘quantitative’ and ‘qualitative’ methods will have to be
abandoned to integrate both approaches in the understanding of the complex
processes influencing population health”.
Rationales for conducting mixed-methods research
A common reason for using mixed methods as a research strategy is for its
ability to create a synergistic effect and thereby aid in the development of a
research project (for example, using findings from qualitative interviews for
formulating survey questions). Two other major reasons for conducting
mixed-methods research are triangulation and complementarity (HesseBiber 2010). Triangulation refers to the use of more than one method in
studying the same research question in order to find convergence of the data;
it is, in other words, “the display of multiple, refracted realities
simultaneously” (Denzin & Lincoln 2003: 8). Complementarity involves the
use of both qualitative and quantitative data in order to investigate the
research problem to the fullest. Both triangulation and complementarity are
thus useful for cross-validation, but while the former aims to enhance the
credibility of the findings, the latter can offer a more thorough comprehension
of the research problem (Hesse-Biber 2010). As Teddlie and Tashakkori
(2009: 33) write, an advantage of using mixed methods is that “it enables the
researcher to simultaneously ask confirmatory and exploratory questions and
therefore verify and generate theory in the same study”.
The term bricolage has also been used to describe and validate mixedmethods research. According to this idea, the researcher is proposed to be
seen as a quilt maker (bricoleur) who deploys different strategies, methods or
empirical materials depending on the research questions. The researcher as
bricoleur thus works “between and within competing and overlapping
perspectives and paradigms” (Denzin & Lincoln 2003: 9), depending on the
context of the research questions. Similarly, pragmatism asserts that the
45 Furthermore, in 2004, Kwan made a call for “hybrid geographies” that would transcend traditional divides,
for example between qualitative and quantitative geographical studies.
48
researcher should focus on the values, or outcomes, of research. The most
fundamental issue for pragmatist researchers is consequently how to choose
the methods and theories/approaches that will most likely provide answers to
the research question. I will return to the issue of pragmatism below, and at
the end of the chapter I will discuss it together with the other strategies
mentioned here (see “Reflections on conducting mixed-methods research”).
Mixed methods – mixed paradigms? Some notes on methodology
The concepts of paradigm, methodology, ontology and epistemology46 require
some attention when discussing mixed-methods research, because criticism
has been raised (see e.g. Sale et al. 2002) regarding the potential paradigmatic
difficulties involved with combining qualitative and quantitative methods in
the same study. The criticism of MM is very much related to the historical ties
between qualitative and quantitative methods, on the one hand, and different
scientific paradigms and their respective methodologies on the other. Very
briefly, quantitative methods developed within sciences grounded in
positivistic realism and objectivism, while qualitative methods arose from
research with interpretivist, constructivist and subjectivist understandings47.
Decades of paradigmatic “wars” have consolidated the associations between
the two types of methods and ontological and epistemological assumptions,
which has led to a common perception of immense differences between
qualitative and quantitative methods (Denzin & Lincoln 2003; see also
Lawson 1995). However, as Lawson (1995: 451) states, the “methodological
dualism” that has long dominated human geography, as well as the social
sciences at large, “is historically produced and is not necessary or inevitable”
(italics in original). In fact, according to Lawson, “quantitative methods rely
on considerable subjective interpretation, and qualitative methods necessarily
entail considerable objectification” (ibid.). However, as methodological
understandings “[lead] the researcher to ask certain research questions and
prioritize what questions and issues are most important to study” (HesseBiber 2010: 11), interpretative, transformative and critical methodologies (as
well as, for example, feminist methodologies) have traditionally been regarded
46 Paradigm can be defined as a system of beliefs and practices, or as “a worldview including philosophical and
sociopolitical issues” (Teddlie & Tashakkori 2009: 21), while methodology is more related to the research
process, and embraces the researcher’s understandings of ontology and epistemology (ibid.). Ontology
concerns the understandings of the nature of existence, human beings and reality, while epistemology relates
to the nature of knowledge, and the relationship between the “observer” and “reality” (Hesse-Biber 2010;
Lincoln & Guba 2003).
47 Positivistic realism and objectivism proclaim that reality is the way it is regardless of whether or not we
observe it, and that this reality can be studied and explained in a neutral, objective way; while interpretivist,
constructivist and subjectivist understandings imply that any apprehension of reality is made by means of
interpretation, and that all knowledge about reality – as well as the nature of reality – therefore consists of
subjective interpretations (Lincoln & Guba 2003).
49
as qualitative, while positivist and post-positivist methodologies have been
seen as quantitative – because of the type of research usually conducted within
these traditions48.
Nevertheless, as Teddlie and Tashakkori (2009: 12) state, “[a] methodological
perspective is not inherently quantitative or qualitative in terms of its use of
method… […] In fact, qualitative and quantitative methods are carried out
within a range of methodologies”; for example, a critical theorist can conduct
quantitative studies, just as a post-positivist can use qualitative methods.
Similarly, Lawson (1995) argues that it is necessary to distinguish techniques
(methods) from methodological positions. For, in contrast to research
methodology, research methods are “specific strategies for conducting
research” (ibid. p. 21). Important to keep in mind, however, is that “the
method is but the tool” while “the methodology determines the way in which
the tool will be utilized” (Teddlie & Tashakkori 2009: 17). In relation to this,
Lawson (1995) states that we as researchers must acknowledge and take
seriously the fact that we “mark the knowledge that we produce” (ibid. p. 452),
and that the use of one method or the other (i.e. qualitative or quantitative)
does not absolve us from the fact that our understandings are partial and
situated49.
Mixed-methods research can also be approached differently depending on the
researcher’s methodological standpoints – from a qualitative or a quantitative
standpoint, or somewhere between the two (Hesse-Biber 2010; Johnson,
Onwuegbuzie & Turner 2007). This is important to recognize, since it
influences the way methods are mixed and utilized (how much the research
aims to confirm or explore issues, for example), and since it – if unnoticed –
may introduce difficulties of a paradigmatic kind into the research process.
For example, if, as a researcher, one were positioned in either of the abovementioned paradigmatic “extremes” (e.g. positivism), and in a mixedmethods study used contradictory ontological and epistemological
understandings from another “extreme” (e.g. interpretivism), problems could
obviously arise in the research process. These potential difficulties in a mixedmethods study are clearly something that should be acknowledged. However,
there are paradigms whose underlying elements can be blended more easily
48 For example, researchers following interpretative methodologies have often premiered the study of humans’
lived experiences, while those following transformative and critical methodologies have emphasized, for
example, power relations and questions of social justice in their research. Researchers following positivist and
post-positivist methodologies, on the other hand, have tended to see hypothesis testing and causality as the
main goals of social inquiry (ibid.; see also e.g. Lincoln & Guba 2003).
49 Lawson (1995) provides directions for how a post-structuralist feminist – who commonly uses qualitative
methods – can do quantitative analysis in ways so that it does not “violate” methodological understandings. She
cautions against using inferential statistics, and argues that counting should only be used descriptively for
“carefully contextualized relations” (ibid. p. 454), for instance for describing relations of power, illustrating the
results of the exercise of power, or conducting exploratory analysis to reveal patterns in places.
50
(e.g. positivism and post-positivism, or realism and subjectivism). Thus, if
one belongs to paradigms that can be blended, the issue of commensurability
– and the mixing of methods – becomes less problematic (Lincoln & Guba
2003). In today’s research practice, neither qualitative nor quantitative
methods can be said to belong to a specific discipline, with empirical material
of a quantitative character occasionally used by qualitative researchers and
vice versa. Additionally, at least within the social sciences, the majority no
longer adheres to conventional positivism, which perhaps makes the task of
combining different methods and approaches less problematic (Johnson &
Onwuegbuzie 2004; Denzin & Lincoln 2003; Teddlie & Tashakkori 2009).
Pragmatism has been advocated in relation to this, and is regarded by several
scholars as the philosophical partner of mixed-methods research (e.g.
Johnson & Onwuegbuzie 2004; Teddlie & Tashakkori 2009; and Morgan
2007). In short, pragmatism is concerned with finding a middle ground
between earlier paradigms (Johnson & Onwuegbuzie 2004), and finding a
workable solution for mixed-methods research. It thereby rejects “dogmatic”
philosophical standpoints in favour of a focus on the search for answers to
research questions (from whatever methodological standpoint, and by
whatever method) (Teddlie & Tashakkori 2009). Pragmatism nevertheless
holds some standpoints of its own. First, it sees the research process as an
inductive-deductive cycle, involving both inductive and deductive
reasoning50. Second, pragmatists question the epistemological dualism of
objectivity and subjectivity (usually stressed by positivists and constructivists,
respectively) and instead emphasize intersubjectivity, which is thus a reflexive
orientation, stressing openness about how knowledge is produced in the
interplay between researcher and research subject, and about the researcher’s
movement between different frames of reference. Third, ontologically,
pragmatists often adhere to the realist view (stating that an external reality
exists independent of our minds) but, at the same time, deny any claims of
truth regarding this reality (hence, they say that there are multiple viewpoints
of social realities). Following this, pragmatists working quantitatively believe
that causal relationships between variables may exist, but that they are
transitory and hard to identify (Teddlie & Tashakkori 2009; Denzin & Lincoln
2003).
Besides pragmatism, as mentioned, there are a number of research strategies
today that are used for describing and validating mixed-methods research
(e.g. triangulation, complementarity and bricolage), which makes the mixed50 Qualitative researchers usually employ inductive reasoning, moving from the specific (observations, facts)
to the more general (theory), while quantitative researchers employ deductive reasoning, working from the
general to the particular. Mixed-methods researchers thus employ both these types of reasoning, in an ongoing
process – the inductive-deductive cycle (Teddlie & Tashakkori 2009).
51
methods process more manageable. Nevertheless, there is still a need for those
conducting mixed-methods research to be conscious of their own stance on
paradigmatic and methodological issues, in order to be able to mix methods
in a research project (Hesse-Biber 2010). At the end of this chapter, I will
return to a discussion on how the mixed-methods approach was implemented
in this thesis, and thereby share some of my own methodological
understandings in relation to the use of mixed methods. The advantages and
disadvantages involved in applying a mixed-methods approach will also be
discussed.
The fieldwork
The study’s empirical material, consisting of interview and survey data, was
gathered through fieldwork in two settings in Nicaragua. For practical
reasons, the fieldwork was carried out in the form of shorter, repeated visits.
The first four fieldwork periods took place between 2006 and 2008 (one visit
each semester), and the last took place in 2013, seven years after the first visit.
The length of these fieldwork periods varied; three visits lasted for two to three
weeks, and another lasted six weeks. The longest stay, in 2007, lasted three
months. In all, I spent around six months in Nicaragua doing fieldwork for
this study.
During the fieldwork I also acquired knowledge about the research topic and
context through other ways than only the interview and survey studies. The
most important secondary source was naturally academic research and other
literature relevant to the study. I visited Managua to meet with social science
researchers at the university, and with persons involved in a network working
on migration issues (Red Nicaragüense de la sociedad civil para las
migraciones). Furthermore, on one fieldwork trip (in October 2007) I paid a
short visit to Costa Rica, where I met researchers with a great deal of
knowledge about the Nicaraguan-Costa Rican migration process, and who had
also conducted research on the situation of Nicaraguan immigrants in Costa
Rica. I also briefly visited La Carpio, a neighbourhood on the outskirts of San
José where many Nicaraguan immigrants live. In Nicaragua, I also gained
useful insight through doing “nothing”; for instance, talking to people (in
restaurants, parks, offices, hotels, etc.), overhearing conversations, and
watching people in their everyday activities. Other important sources of
information were broadcast news and printed media (mainly the daily
newspapers La Prensa and El Nuevo Diario). This type of fieldwork could be
regarded as similar to “participant observation”, the main ethnographic
research method. However, since I did not explicitly use ethnographic
methodology, I prefer to call the work I did “observant participation”, in line
52
with Helgesson (2006: 66) (and similar to Tedlock 2003, who speaks of
“observation of participation”). My use of observant participation in this study
entailed being observant of matters of special relevance to my study when
participating in conversations, activities, events, etc.
I acknowledge that fieldwork can be problematic (see e.g. Staeheli & Lawson
1994). First of all, for research purposes the “field” must be delimited (and
thereby constructed). Even though fieldwork “necessarily involves being in a
place and focusing on context and everyday experience” (ibid. p. 98), it is
important to include not only place-based (local) but also nonlocal processes
(i.e. processes on multiple scales) in the conceptualization of the field, so that
it is not portrayed as (for example) fixed and homogeneous, which could
contribute to the perpetuation of power structures and difference (ibid; see
also Katz 1994). Another important question – especially in relation to
fieldwork in which the researcher is an “outsider”, or fieldwork including
marginalized people and groups – is whether it is possible for the researcher
to understand and represent the field correctly. According to Staeheli &
Lawson (1994), this difficulty should not intimidate the researcher from doing
fieldwork, but it necessitates a recognition that what we may know about the
field is partial and situated.
Getting to know the field, and holding test interviews
During my first visit to Nicaragua in October 2006, I focused on getting
acquainted with the people I would be collaborating with during the study, e.g.
researchers and other staff members at CIDS and CHICA (see Chapter 1 for
further details on these organizations). I also spent time getting to know the
two settings where the work would take place. Besides this, I held a couple of
test interviews in León, with assistance from a researcher from CIDS (Wilton
Pérez), as well as one interview in Cuatro Santos51. The purpose behind
conducting these interviews was to see whether the interview questions I had
prepared beforehand in Sweden functioned well in the setting, and served to
give answers to the research questions. Two of the test interviews illuminated
some very interesting aspects, and are therefore part of the material used in
the analysis. However, the major lessons from the test interviews were, first,
that I would choose to do the next interviews without an interview guide
containing pre-formulated questions, as I found it difficult to engage in the
conversation with a piece of paper in my hand; and, second, that I needed to
become much more fluent in Spanish before conducting more interviews,
since I wished to do them alone without an interpreter as I experienced that
this obstructed the “flow” of the conversation.
51 Accompanied by my colleague, Gunnar Malmberg.
53
The interview study
During my second visit to Nicaragua in March to May 2007, I did most of the
interviews for the qualitative study. These were conducted towards the end of
my stay, when I felt I mastered the language well enough. Still, I must admit
that I sometimes experienced that my skills in Nicaraguan Spanish were
halting, and occasionally caused misunderstanding (this was particularly
noticeable when listening to the recordings). Still, the interviews provided
enough rich empirical material for the qualitative analysis.
Based on the experience from the test interviews, I chose to conduct the
interviews without following a guide. The interviews were therefore more
similar to informal conversations (unstructured interviews), rather than
“question-answer” interviews, and were largely guided by the interviewee’s
wishes or interests. Of course, my ambition was to cover certain themes during
the interviews, but I kept these in my head and tried to direct the interviewees
to these issues as much as possible. Sometimes there was no need for further
direction; in these cases I tried to capture the themes as the interviewee spoke.
Moreover, inspired by the biographical approach (see p. 63), I wanted to
explore the connections between migration and health in the interviewees’ life
histories. All interviews (except for the test interviews) therefore centred
round the biographies of the persons involved. To reach the ambition I had
set, I started the interviews with one broad question, or invitation, which went
something like this:
“I would like you to tell me about your life...where you were born and raised, if you’ve
moved on any occasion. About your educational background and working experience.
About your family: wife/husband/partner, children, parents, brothers, sisters? Where
they were born, if they have moved, about their education and work experience...
About your health situation and the health of your family members... If your/their
health situation has been affected by migration... And so on...”
This inviting question made most respondents quite relaxed, and many told
their story without hesitation. For those who did not start speaking
spontaneously, I further suggested that they begin with when and where they
were born. I let the interviewees speak freely with as few interruptions as
possible, and asked follow-up questions as the interview progressed
(concerning the themes I wanted to cover, and to clarify matters or help the
respondent keep to the subject matter). Even though the interviews were thus
rather unstructured in format, they all covered the same themes (either
spontaneously or through my direction), as listed below:


Background information on the interviewee and his/her family (work,
education, etc.)
Personal experience of migration
54





Migration of significant others (close family, relatives, friends)
Health – personal and that of significant others (problems, changes
related to migration)
Use of and access to health care
Help between significant others in the person’s social network
The economic and social situation in Nicaragua and in destination
countries (e.g. Costa Rica and the United States)
Recorded interviews were conducted with 15 persons (5 men and 10 women).
Besides these recorded interviews, several other conversations of a more
informal character also took place during the fieldwork; two such talks are
used in the analysis (with Esmeralda and Aleyda) (see Table 1, next page). I
came into contact with the interviewees in many different ways – through
friends, by having met them on the street or at hotels, and occasionally
through selection from the HDSS (see below and Chapter 1, for further
information on the HDSS). The interviews were conducted in several different
places; at workplaces and in homes, at hotels and at offices. The length of the
interviews varied greatly; the shortest was only 30 minutes long, while the
longest lasted over two hours. The number of times I met the interviewees also
varied; some I only met once, whereas others I met on several occasions, over
a long period of time. Hence, I only conducted follow-up interviews with some
of them. On these occasions, I read through the first interview beforehand to
refresh my memory, and also prepared some questions concerning matters I
found especially interesting or confusing. These talks generally added new
information relevant to the study; however, they are not used in the analysis
in the same way as the recorded interviews are.
Upon finalization, the recorded interviews were carefully transcribed. An
assistant, Yamileth Gutiérrez, did the major part of the transcription work,
because I believed a Nicaraguan would be able to do a more accurate
transcription (as I myself was not completely fluent in the language). When
Yamileth had finished her work, I listened through the interviews and
transcribed the parts that were missing in the first transcription (which made
up quite substantial parts of some of the interviews, but in others only
occasional words). The transcriptions can thus be seen as a product of this
collaboration. Even though my colleague did a large part of the transcriptions,
through my part of the work I developed a thorough familiarity with the
material, which in the end amounted to around 230 pages of written text.
The interviewees
Background information and the migration experience of each interviewee are
presented in Table 1 (next page) (all names are pseudonyms and locations are
55
not exact, in order to ensure the informants’ privacy). As a summary, I can say
that the interviewees were aged between 22 and 60 years, and had various
educational backgrounds and working experience. They originated in both
rural and urban areas, and were presently living either in their place of
origin/birth, in another town, or abroad. Their experiences of internal and
international migration varied a great deal; they were either migrants
themselves, or family members of a migrant (labelled “Left-behind” in the
table). Those who had migrated internationally had experience of both legal
and irregular/undocumented migration (some interviewees had experience of
both types). More thorough descriptions of each interviewee are given on the
following pages.
Table 1: The interviewees
NAME
Gloria
Sandra
Cesar
Juliano
Cindy
Maribel
Fernando
Marta
Santos
Rosa
Joanna
Ana
Carmen
Mercedes
Orlando
Esmeralda
Aleyda
BACKGROUND INFORMATION
MIGRATION EXPERIENCE
60 years, married, 6 children; no schooling
Left-behind
Farmer; C. Santos
28 years, married, 2 children; secondary*
International migrant
Shop attendant; León
Left-behind
31 years, married, 2 children; secondary
International migrant
Taxi driver; León
24 years, married, 1 child; secondary
International migrant
Painter; Miami, USA/León
24 years, married, 1 child; secondary
Left-behind
Housewife; León
39 years, single, 2 children; university
International migrant
Nurse; León
55 years, married, 5 children; primary
International migrant
Town councillor and farmer; C. Santos
Left-behind
Internal migrant
50 years, single, 5 children, primary
House keeper; León
Left-behind
33 years, single, no children; primary
International migrant
Shop attendant/security guard; León
27 years, single, 3 children; primary
Int. and intern. migrant
Hotel cleaner; León
Left-behind
28 years, married, 2 children; secondary
International migrant
Housewife; C. Santos
Left-behind
22 years, single, no children; no schooling
Internal migrant
Housekeeper; León
33 years, married, 2 children; no schooling
Left-behind
Farmer and small enterpriser; C. Santos
34 years, married, 6 children; primary
Internal migrant
Small enterpriser; León
47 years, married, 6 children, primary
Internal migrant
Small enterpriser; León
24 years, single, 1 child, secondary
International migrant
Unemployed; C. Santos (not recorded)
28 years, single, 1 child, university
Commuter
Factory supervisor; León (not recorded)
International migrant
Notes: * highest level of education (either completed or not completed).
56
Gloria. The interview with Gloria, conducted in October 2006 on the
outskirts of a village in Cuatro Santos, is one of the test interviews mentioned
above. Gloria was a 60-year-old woman I met through a research colleague,
who was a leading figure in a development project in the area, as well as
Gloria’s neighbour. Although he stayed in the background during the
interview, his presence might have influenced Gloria to talk about the benefits
of the development project rather than the focus of our interview.
Nevertheless, the interview was interesting and is therefore included in the
study. Gloria and her husband made their living as farmers. They had six
children together; at the time of the interview three of their sons were living
elsewhere. The interview took place on the porch outside Gloria’s house and
lasted about half an hour. During the interview there was a thunderstorm with
heavy rain, and a great deal of chickens, pigs and dogs were running around
our feet. I met Gloria once more in 2008, a year and a half after our first
interview. By that time two of her sons had returned home.
Sandra. The interview with Sandra is the other test interview included in the
study’s qualitative material. It was conducted in León in 2006 with assistance
from Wilton Pérez, who helped during the interview with translation when
necessary. Sandra was included in the HDSS, and we looked her up after
having selected her for an interview since she had lived in Guatemala for
several years. Sandra was born and raised in Chinandega, but had been living
in León for a while. The interview took place in the house where she worked
as a shop attendant, and where she also lived with her two children. Her eldest
son had lived with Sandra’s mother in Chinandega while Sandra was in
Guatemala. Sandra’s husband presently lived in the US, but she herself had no
plans to leave León.
Cesar. The interview with Cesar took place in May 2007 (as did the rest of
the interviews). Cesar was a married man in his 30s, and the father of two
small children. He worked as a taxi driver in León, and when he drove me
across town one day we started chatting in the car. I learnt that he had worked
abroad for several years, mostly in Costa Rica, so I asked if he wouldn’t mind
sharing his story with me and my supervisor, Aina Tollefsen, who was there
on a short visit. The interview, which lasted an hour and a half, took place in
the hallway of a hotel where we all knew some of the staff and felt comfortable.
I met Cesar on all my visits to León. In 2013, the last time we met, Cesar was
working at a retail company just outside León. In 2014, I heard that he went
to Panama to work.
Juliano. I met Juliano through my local Spanish teacher. He was 24 years
old and married to Cindy (see below), with whom he had one child. The
interview took place at his sister’s house in León, where he was spending time
during a visit from the US, where he had lived for four years at that point.
57
Juliano was a US resident, thanks to a petition by his father (who had earlier
been granted residency thanks to his mother, who had come to the US in the
1980s). To avoid the afternoon heat during the interview, we sat in rocking
chairs just outside the entrance to the house; a fan was on to blow away the
persistent flies. Just across the street some kids were playing basketball, and
the next-door neighbours did their best to drown out the twitter of birds by
playing reggaeton at a high volume. We talked for a little less than an hour.
Cindy. I interviewed Juliano’s wife Cindy two days after my talk with Juliano,
on their last day together during his visit, as Juliano was leaving for the US
the next day. Cindy was 24 years old, and had a six-year-old son with Juliano.
Cindy had been a stay-at-home mom and a part-time architecture student ever
since Juliano left for the US. The interview took place at Juliano’s sister’s
house, and lasted about 45 minutes.
Maribel. Maribel was a 39-year-old nurse who lived in León. She had
separated from her husband ten years earlier, and since then had supported
herself and her two children by working in both Nicaragua and Costa Rica. At
the time of the interview, she was working for a non-governmental
organization in León. I met Maribel through a mutual friend who worked at
CIDS, which is also where the interview took place, in a conference room. It
lasted about an hour and a half. In 2013, I learnt from our mutual friend that
Maribel was still living and working in León.
Fernando. I interviewed Fernando when I was out with the CHICA survey
team on a follow-up trip around the municipalities in Cuatro Santos. I selected
Fernando from the HDSS because he seemed to have interesting migration
experience. Fernando was in his 50s and worked as a member of the town
council, as well as a farmer. He lived in a small town, the city centre of the
municipality, with his two youngest children; his three eldest children lived in
other parts of the country and supported themselves. For many years,
Fernando and his wife had run a small shop in their house. After they had been
forced to close the shop due to low revenue, Fernando had gone to the US for
six months to work. At the time of the interview, his wife was working in Spain.
During our talk, we sat on white plastic chairs in the parlour, facing the open
front door. A great deal of noise welled in from the street – from cars, horse
carriages, construction work, roosters, and music. The interview lasted about
45 minutes.
Marta. During my longest stay in León I shared a kitchen with a family who
had a housekeeper by the name of Marta. As time went by, we got to know
each other through our chats by the stove. Marta was willing to share her life
story with me, so late one night when everyone else was out we sat down in
the living room and talked for about an hour. Marta was 50 years old, and was
born in the countryside outside León. Upon separating from her first husband
58
when she was in her 20s, she had gone to León with her two small children to
look for work. After some time she met a new man, with whom she had three
more children. Twenty-three years later, Marta’s husband decided to go to
Costa Rica to look for work and she started working again, as a housekeeper.
I visited Marta on each of my visits to Nicaragua, and talked about how life
had evolved since my last visit. In 2008, as well as 2013, she was living and
working in the same house as before. Life was pretty much the same, and on
both occasions she said she was rather pleased with life.
Santos. I met Santos by chance on a visit to a shop in León. When I told him
about my work, he immediately mentioned that he had many experiences of
migration that he would gladly share with me. The interview took place at my
house late one night, a couple days after our first meeting, and lasted almost
two hours. Santos was 33 years old and had made a living mainly from lowskilled, short-term, low-paid jobs both in León and in the countryside. He had
made three attempts to go abroad (to the US and to Costa Rica) in order to
look for work. Santos was a great narrator, speaking with sincerity and
expressing a great deal of feeling. As I will come back to later, the interview
seemed to have a therapeutic meaning for him since it gave him the chance to
put into words some very difficult experiences in his life. I saw Santos from
time to time during my stays in León. In 2008, he was still working in the same
shop, although with other tasks.
Rosa. Rosa was working as a cleaner at a hotel I frequently visited during my
stays in León. Her working schedule was quite tough, and because of this the
interview had to take place in a hotel room after a long day’s work. Despite
this, Rosa talked unceasingly for over two hours about her life, which had been
very eventful even though she was only 27 years old. Rosa had moved many
times since her childhood, both within Nicaragua and abroad. At the time of
the interview, her three children were living with her mother in another town
quite far away, while Rosa stayed at the hotel where she worked. When I saw
Rosa a year later, in 2008, her life situation was practically the same. In 2013
she was still working and living at the same hotel, and her children were still
living with her mother, although a bit closer to León.
Joanna. I interviewed Joanna in her home, in connection with a follow-up
of the survey in Cuatro Santos. She was 28 years old, and lived with her two
children in the outer parts of a small town that lay surrounded by a stunningly
beautiful, lush and mountainous landscape. She had recently returned to her
birthplace after spending seven years working in Guatemala. Her husband
was working as a truck driver, travelling around Central America. The
interview was rather short, just over half an hour, because of Joanna’s
toddler’s need for attention.
59
Ana. Twenty-two-year-old Ana came from a small rural community “in the
mountains” – as she said – far from León, where she was residing at the time
of the interview. She had left home at 15, and since then had made a living on
her own, mainly through working as a live-in maid. I met Ana through her
current employers, whom I knew from work. Our talk took place in their living
room on a hot afternoon, and lasted about an hour and a half. The children
who lived in the house sometimes passed by, on their way out or to the kitchen,
but Ana didn’t seem intimidated by this, except that she lowered her voice
when talking about delicate matters. In 2013, I learnt from our mutual friend
that Ana had moved back to the “mountains” where she came from.
Carmen. I met Carmen in connection with a survey follow-up in Cuatro
Santos. Carmen was 33 years old, and lived with her two children at her
stepmother’s house, in the outer parts of a small town in Cuatro Santos. She
and the family made their living from farming and animal-keeping, as well as
from making and selling handicrafts made of pine. At the time of the
interview, Carmen’s husband had been working in the US for a year. Carmen’s
stepmother, “Aurora”, was also present during the interview and sometimes
participated in our discussion. This didn’t seem to affect Carmen negatively;
on the contrary, it seemed as if her presence made Carmen a bit more
comfortable with the interview situation. During the interview we sat outside
the house; occasionally, a neighbour, a dog, or a pig passed by on the trail next
to where we were sitting. The coffee and cake I’d been served were invaded by
small, red ants when I put them down on the bench next to me. The interview
lasted well over an hour.
Mercedes and Orlando. Thirty-four-year-old Mercedes was a beautician I
got in touch with through a mutual friend who was one of her clients.
Mercedes’ husband Orlando, aged 47, also took part in our discussions since
he was sitting just beside us during the interview, working in his artisan
workshop, which took up half of the house. They both openly shared their life
histories with me during the two-hour interview. Mercedes and Orlando were
born in two small neighbouring villages north of León, but had in different
ways and at different ages left their places of origin and ended up in León.
When Mercedes and Orlando met, he had an artisanry business and she soon
moved in and started working with him. Over the years they had six children.
Due to unfortunate circumstances, a couple of years prior to our interview they
had moved to a less well-off neighbourhood in León. Orlando still worked with
his artisanry, and Mercedes received clients in their home. I visited Mercedes
and Orlando once more in 2008. At that time they said life had become worse,
and that they were thinking of going abroad to look for work. In 2013, I learnt
from our mutual friend that Mercedes and Orlando had separated when
Mercedes was expecting their seventh child. She and her children were now
living with a new man, and she was still working with her beauty business.
60
Esmeralda. In a rather small house with clay brick walls and an earthen
floor in a rural part of Cuatro Santos, lived Esmeralda, 24 years old, with her
year-old son and 11 other family members. I got in touch with her during a
follow-up tour of the survey in the area, and asked if I could sit down for a talk,
which lasted about 45 minutes. Because of the family’s poverty, Esmeralda
had been obliged to go abroad and look for work after graduating from
secondary school. She had therefore followed her brother, who was in El
Salvador, and worked there for three years as a maid and a clothing vendor.
She had returned to her birthplace about a year before our interview, when it
was time to give birth to her child. At the time of the interview, Esmeralda did
not mention any plans to return to El Salvador, or to go anywhere else.
Aleyda. In a restaurant in León one day I started talking to Aleyda and her
three-year-old daughter, who were sitting beside me. As it turned out, they
lived next to the hotel where I was staying, and later that evening when I was
passing by they invited me in for a longer chat with the family. Aleyda, who
was a pharmacist, had been commuting on a weekly basis for the last three
years to her job in Chinandega, while her daughter stayed in León with
Aleyda’s mother and the rest of the family. Two of her brothers lived abroad
(in Costa Rica and the Netherlands). Aleyda was also thinking of going abroad,
to the US where one of her closest friends lived. I learnt in 2008 that she had
gone through with this plan. She had been approved for a tourist visa to the
US, thanks to her Nicaraguan friend who lived there, which she overstayed in
order to look for work. I saw her when she returned to León for a visit;
thereafter, she returned once more to the US.
The interview situation
In my experience, interviewing is a work that evolves over time, as a process.
The first interviews are often rather tentative and almost stumbling, whereas
later ones more take on the form of informal conversations. Each interview is
unique since the interviewees are different people with different experiences,
and the information provided by each interview is consequently also always
unique. I therefore believe it is fruitless to ask exactly the same questions, and
to try to cover exactly the same issues in all interviews (for instance by
following an interview guide). Instead, I find it necessary to adapt the
questions, and the way they are posed, to each new person, and to follow his
or her personality and interests. Like in similar research situations (other
types of interviews, as well as in surveys), the interviewees in this study
constructed their answers, narratives and life stories so as to fit to the
interview situation (Arvidsson 1998; Riessman 2008). Therefore, there were
almost surely issues that were omitted, as well as emphasized, and the
61
interviewees most probably made an effort to picture themselves as “good”
people. Although there thus are variances between the interviews regarding
the information they provide, each interview offered new, different and
specific insights that added to the analytical process. To give just one example,
the most important insight from the interview with Gloria was how
emotionally affected she was by her sons’ absence from home due to their
work abroad and in other parts of Nicaragua.
I tried to make the interview situation as comfortable as possible so that the
interviewees would feel they could trust and confide in me. In accordance with
other qualitative health researchers (e.g. Hewitt 2007; De Haene et al. 2010;
Orb et al. 2001; Paavilainen et al. 2014; and Siriwardhana et al. 2013), I believe
it is particularly important to pay attention to ethical aspects in research on
sensitive, potentially delicate issues (e.g. health), as well as in studies
including so-called vulnerable groups (e.g. migrants). Besides acquiring
ethical approval from the medical faculty at León University (UNAN-León,
Comité de Ética para Investigaciones Biomédicas, ACTA no. 15, March 28
2008), I also took several precautions to ensure ethical conduct, as well as to
instil a feeling of informality and comfort during the interviews. First of all, I
informed the interviewees of the purpose of my study, and what themes I
wished to discuss with them. I also emphasized that their participation was
completely voluntary and that their privacy would not be adventured. The
interviews were conducted at places and times according to the interviewees’
wishes, and before and during the interview I stressed that they could decline
to answer my questions or end the interview whenever they wanted.
Moreover, I listened carefully, with empathy and respect, throughout the
interviewee’s story. Instead of taking notes I used a small, almost unnoticeable
MP3 player to record the interview, which I of course asked for permission to
do before starting the interview.
Even though I did my very best to ensure a sense of openness, respect, trust,
and confidence, there might have been moments when my position as a welleducated, well-off, young, white European woman affected the interview and
the interviewee in ways I did not intend. Power relations are inherent in all
social relations, even in interview situations. By letting empathy and respect
characterize these situations and relations, however, there is a greater chance
that such power relations will not become intimidating (Charmaz, 2003;
Schwandt, 2003). Just as my social position may have affected the interviews,
I also believe my personality may have had some impact. For instance, my
rather emotional way of acting might have influenced the interviewees to also
express emotion. Even though I mostly felt very fortunate that the
interviewees trusted me enough to confide in me and talk to me about
sometimes very delicate matters, this also led to a closeness that at times
62
became difficult to handle. Particularly the interview with one male
interviewee, Santos, was very “heavy”, as his narrative was filled with grim
events, and as he also gave a depressed impression and even talked about
being suicidal (see McGarry 2010, on the emotional effect of qualitative
research on sensitive issues). As Santos pointed out afterwards, the interview
had been a way for him to talk about his hardships for the first time, and,
luckily, he felt that our talk had made him feel a bit better, as he had had the
chance to put his experiences into words. During as well as after the interview,
I also experienced that it might have had a therapeutic meaning for him.
“Storytelling”, in both therapeutic and research contexts, may in fact have a
healing effect, as I will return to in Chapter 6 (see e.g. Pennebaker 1995;
Pennebaker & Seagal 1999; and Rosenthal 2003). My relationship with Santos
became somewhat strained after the interview; he was very persistent when
we occasionally met, almost demanding that we should meet and that I should
help him in various ways (for example financially). This could have affected
the analysis of this interview – though I don’t believe it has – which is why I
discuss it here. I also find it very interesting from a methodological point of
view; it serves as an example of the importance of the relationship between
researcher and informant in qualitative research and how this relationship, in
itself, may provide empirical material that can be used in the analysis and for
answering the research question.
Qualitative research approaches and methods of analysis: the
biographical approach and constructivist grounded theory
The interview study includes a combination of two different qualitative
research approaches. The interviews were carried out based on the
biographical approach, as described below. The analysis of the interview
material was then performed in two ways – by use of constructivist grounded
theory, and by means of the biographical approach, through which the
constructivist grounded theory analysis could be situated in time, as part of
the individual’s life course.
“[M]igration exists as a part of our past, our present and our future;
as part of our biography” (Halfacree and Boyle, 1993: 337)
Biographical research seeks to understand individuals’ life experiences in
their daily lives, as placed within the contemporary cultural and structural
context (Roberts 2002). The empirical material analysed within biographical
research – for example biographies, narratives, life histories, and life stories
– focuses on the stories of individuals, and on seeking to understand the
individual’s life within its social context. The approach is thereby a way to
place and understand societal changes, through the individual’s experiences
63
and interpretations. According to Arvidsson (1998), biographical interviews –
in their strictest form – start with the interviewee’s birth or origin, and move
along in time until the present. They may, however, also take on other forms,
for example that of interviews starting with a biographical description, which
is then used as a background when focusing on a certain societal phenomenon
or historical epoch. Another form of biographical/life history interviews are
those that start with a short chronological biographical description, and
thereafter focus on specific periods in time or themes, though still as part of
the life history. In migration research, the biographical approach has been
used for many decades (see Skeldon 1995 for an overview). A starting point in
this research is that migrants (just as other human beings) are socially
embedded, and that they influence, and are influenced by, the social world
that surrounds them throughout the life course (Findlay & Li 1997). In
biographical migration research, migration is firstly understood as an “action
in time” (Halfacree & Boyle 1993: 337) rather than a discrete act at a particular
point in time. The time aspect is thus crucial, and an individual’s decision to
migrate is believed to be situated in his/her entire life history. Moreover, the
approach also emphasizes the “rootedness of the migration in everyday life”
(Halfacree & Boyle 1993: 339). Hence, migration events are believed to be
connected to many different dimensions of life, and the decision to move is
seen, for example, as related to a variety of factors (e.g. the economic situation,
family relations and health concerns). Additionally, migration is regarded as
“a manifestation of an individual’s identity” (Findlay & Li 1997: 34) and is thus
understood as a highly cultural event (Fielding 1992) that reconfigures social
identity. For example, migration concerns and affects the worldviews, values
and attachments of both migrants and their families, as well as of the societies
of origin and of destination. By means of the biographical approach, the
complexity surrounding migration can thus be highlighted, making it possible
to gain “insights into the dynamics that shape the actions of individual
migrants during their life course” (Tollefsen Altamirano 2000: 17). Hence, it
is a way to get “glimpses into the lived interior of migration processes”
(Benmayor & Skotnes 1994: 14). I was highly inspired by the biographical
approach in the interview study, and the interviews can be described as a mix
of the biographical interviews outlined by Arvidsson (1998). They all started
with biographical descriptions, but then focused not only on the themes under
investigation (migration and health, social relations, etc.) but also on specific
periods in time, historical epochs, and societal phenomena. The interviews
always returned to the person’s life history when it was sidestepped; it thus
served as a background for the interviewee’s descriptions of the themes,
periods, or phenomena. Not all interviews captured the whole life history of
the interviewee; in these cases, only specific parts of the person’s life course
were covered in the interview (see Tollefsen Altamirano 2000 for a similar use
of the biographical approach).
64
The other qualitative strategy used in the thesis is constructivist grounded
theory, which stems from the grounded theory (GT) method advanced by
Glaser and Strauss during the 1960s and further developed by Strauss and
Corbin during the 1980s and 90s (Charmaz 2003). The ambition of GT is often
to create or develop a new formal theory from empirical material that is
“grounded” in a natural setting, or, in more modest phrasing, to “generat[e]
new ideas, categories or perspectives that can shed new light on a
phenomenon” (Tollefsen Altamirano 2000: 15). GT findings are furthermore
meant to generalize across cases, in contrast to narrative approaches
(Riessman 2008). There are several guidelines for “doing” grounded theory.
Some of the most common strategies are: (i) a simultaneous collection and
analysis of data (mostly interviews), (ii) data coding processes, (iii) memo
writing for constructing conceptual analyses, (iv) sampling for the refinement
of emerging theoretical ideas, and (v) integration of the theoretical framework
(Charmaz 2003). The coding process usually consists of coding the data in, for
instance, actions, events, processes, experiences, and meanings (initially lineby-line or using larger pieces of the text, and later selective/focused coding,
which is more conceptual). After this foundational work the process of
synthesizing and explaining the data follows, through categorizing the codes
(categories often subsume several codes). According to Kathy Charmaz
(2003), one of the purposes behind Glaser and Strauss’ work was to
systematize qualitative research in order to make it legitimate in the eyes of
quantitative researchers who dominated the social sciences at the time. After
criticism from post-modernist and post-structuralist qualitative researchers,
Strauss and Corbin therefore (in a post-positivist spirit) started emphasizing
the importance of “giving voice” to the respondent, and of recognizing the
respondent’s own view of reality (and that this reality can differ from that of
the researcher). Charmaz (e.g. 2003) has taken the method further from its
positivist/objectivist connotations, and argues for a constructivist grounded
theory (henceforth also called CGT), since she, in contrast to original
grounded theorists, sees data (e.g. interview data) as “narrative constructions”
or “reconstructions of experience”, and “not the original experience itself”
(Charmaz 2003: 258). Consequently, says Charmaz, a constructivist working
with GT sees the study findings as a product of the interactions between
researcher and research subject. Since the interviews, and the results
stemming from the analysis, are created in that specific context, they should
therefore be regarded as “negotiated accomplishments” (Fontana & Frey
2003). Furthermore, constructivist grounded theorists “aim to include
multiple voices, views, and visions in their rendering of lived experience”
(Charmaz 2003: 275). The researcher should thus include both the
researcher’s and the research subject’s meanings of lived experience in the
analysis, instead of merely delivering the researcher’s own version of what has
been said or has happened. In relation to the research process, constructivist
65
grounded theorists moreover try to go “inside” the experience of the research
subject and thereby find active codes – describing what the subject is doing
and/or what is happening – that can later form categories that approximate
the images of experience. In contrast to the original GT method, which
commonly focuses on the researcher’s interpretations of what informants say
or do, CGT thus tries to come closer to the meaning of lived experience, and
leads to a text in which “[t]heory remains embedded in the narrative, in its
many stories”, and “readers might sense and situate the feeling of the research
subject” (ibid. pp. 278, 280).
Qualitative analysis in practice
I would say that the analysis of the interviews started already while I was
conducting them. During the interview, I got a sense of what the most
significant themes concerning migration and health were. I could also sense
the interviewee’s feelings about what was said. I kept these impressions with
me during the continued research process, and they later informed the
analysis. Directly after an interview, I wrote in a field diary about the interview
and the information it had provided. I also continued taking notes while I was
working with the transcriptions, and when I later read the transcribed
interviews while listening to them. During the second reading of the
interviews I initiated the CGT-coding process first coding the interviews word
by word, then line by line, sentence by sentence, and paragraph by paragraph.
I used both in vivo codes, i.e. the person’s own word(s), and analytical codes
based on my own interpretations and ideas. These codes were then grouped
under more abstract codes (axial codes) based on the patterns or themes that
emerged from comparing the shared characteristics and meanings of the
initial codes. The abstract codes were thereafter grouped into categories, or
themes, that integrated a substantial number of the codes. Most of the coding
was done by means of paper and pen, but part of it was also done in a computer
programme for the analysis of qualitative material (MAXQDA10). The
themes/categories were changed and refined many times during the analytical
work, even though their content (the codes) remained the same. The first,
rather tentative, categories included for example “moving abroad or to town”,
“life in a new country or town”, “health problems or improvements”, and
“social relations and support”. Some time later, I read the interviews once
more and went through the themes and their connected codes. I then added
the category “making a living”, and split the theme about health into two
themes – “mental health/emotions” and “physical health”. At this point I also
performed a selective coding of feelings/emotions since this emerged as an
important theme in all interviews. When I began writing the empirical
chapters, after more months, I looked through the material again and decided
to change the labels of the categories once more, having found a new and more
66
appropriate/convenient division of the material. My closest colleagues also
took part in the analytical process, through reading and discussing the
interviews. During the whole process I also studied different theoretical
perspectives and previous studies on the research topic. The analysis can
therefore be seen as an abductive process whereby I switched between theory
and data. The final results of the analytical process can be seen in the themes,
categories and narratives presented in the empirical chapters.
In the analysis, I used CGT to analyse the “whole picture” of migration-health
relations in the interview material. CGT was indeed a fruitful way to get an
overview of these relations; however, even though I made use of the
constructivist version of GT, I felt that the complexity in people’s lives was
lost. I thus experienced a need to complement the GT analysis with a more
narrative analytical strategy, and therefore decided to analyse and present the
results in light of the interviewees’ biographies, by use of the biographical
approach. In this way, the interview narratives could be seen as part of the
interviewees’ past, present and future.
The two-step survey study
At the same time as I was conducting the interviews, I was working with the
research teams at CIDS and CHICA in preparation for the survey, which would
be carried out in two steps. Before going into detail about the survey study, I
will first provide more background information about the Health and
Demographic Surveillance System (HDSS) in the two study settings.
The HDSS in León and Cuatro Santos
The HDSS in León dates back to the early 1990s, when two cross-sectional
household surveys were conducted (in 1993 and 1996) as part of a child and
reproductive health project. The study population was selected by use of a
cluster sampling framework, in which 50 urban and rural residential areas
were selected52, covering a total of 43,765 individuals residing in 7,789
households (which represented 22% of the total population of León). An
epidemiological database was constructed, and in 2002-2003 this database
was updated; this time also including new sample clusters in the rural zone.
By then, the HDSS monitored 54,647 persons living in 10,994 households,
which equalled 30% of the total population in León. Two more follow-ups of
52 A cluster was defined as a geographical area with a population of 700-1,000 inhabitants. At the time, 208
clusters were identified in León, of which 50 clusters were randomly selected for the study (Peña et al. 2005,
2008; Pérez 2012).
67
the baseline in León have been conducted: the first in 2005, and the second at
the same time as our survey, in 2008 (Peña et al. 2005, 2008; Pérez 2012).
The HDSS population at the time of our survey consisted of around 56,000
individuals, residing in over 13,000 households (31% of the total population
in León municipality) (see Figures 2 and 3; design: Margarita Chévez, CIDS).
Figure 2: Study areas in León municipality, 2006.
Rural areas in grey, urban in black.
Figure 3: Study areas in urban León, 2006. In grey.
68
In Cuatro Santos, the work with the HDSS was initiated in 2004. Since the
beginning it has covered all residents in the area, which in 2007 amounted to
24,568 persons residing in 4,828 households53. Figure 4 shows the dispersal
of houses in the study area’s four municipalities (map design: CIDS).
Figure 4: The HDSS in Cuatro Santos, 2005.
Houses marked as black dots.
The major bulk of data collected since the beginning within the frame of both
surveillance systems mainly concerns three categories: a) socio-economic
background information, e.g. age, sex, education, occupation, household
composition, housing conditions, poverty levels; b) vital/demographic
events, i.e. births, deaths, in- and out-migration; and c) reproductive health
and child health, e.g. obstetric histories of women of reproductive age,
indicating child survival. The HDSS data are commonly collected on the
household level, by means of interviews with the head of household, or if
he/she is unattainable, anyone at home over the age of 16. The information on
reproductive health is, by contrast, collected directly from the woman herself
(Peña et al. 2008; Zelaya Blandón et al. 2008; Pérez 2012). (A more detailed
description of the survey procedure and the HDSS data will be presented
later).
53 According to government statistics the area’s population was somewhat larger in 2007, with 26,765
persons (INIDE 2007a).
69
Survey step 1: singling out individuals
We had thus been given the opportunity to conduct our survey within the
frames of the HDSS in both areas. However, since the HDSS is based on
household data, and as we wished to direct our questions to individuals for the
purposes of this study, it was necessary to design the survey in two steps – the
first to single out individuals who could constitute a sample, and the second
to gather information from the individuals in this sample (see Figure 5, p. 75,
for an overview of the two-step survey).
The first step of the survey was carried out during my fieldwork in spring
2007. Since the HDSS in Cuatro Santos was about to be updated, and a substudy would take place in León, we could include a set of additional questions
along with those from the original HDSS questionnaires (concerning health
status, use of health services and medicine, and reception of remittances),
which would give us the necessary information to make a sample for the
second step of the survey. The specific questions posed in the first step were:
1)
2)
3)
4)
5)
6)
Has anyone in the household been sick in the past three months?
Who?
In what way (what disease/illness)?
Did he/she visit any health care services?
Did he/she use any type of medicine (occidental and/or traditional)?
Has anyone in the household received any remittances in the past
three months?
In Cuatro Santos, all households – approximately 4,800 – were asked these
additional questions. In León, we selected every fifth household in the urban
sector – amounting to 2,500 households, of the total of 13,000 households
included in the HDSS – primarily due to limited resources, but also because
the material would have been too extensive otherwise. Following the same
working procedure as that of the original HDSS surveys, the additional
questions were asked of one person in each household (most often the head of
household), but covered information about all members of the household.
Through the additional questions, we retrieved individual information from a
total of 40,313 men and women – 13,171 in León (24% of the HDSS
population) and 27,142 in Cuatro Santos (all inhabitants) – which thus made
up the study population for our survey (see Table 2, p. 72). Based on the
information from Step 1, we could distinguish between individuals who had
been sick or healthy, and what illness those with health problems had
experienced (categorized as acute, chronic or other). We could also say
70
something about the use of health care services and medicines, and of the inflow of remittances in the study areas.
Survey step 2: construction of sample and questionnaire
On my third visit to Nicaragua in October 2007, the work of constructing a
sample for the second step of the survey continued. At this moment in the
process, we connected the data gathered during the first step to other HDSS
data available in the databases at CIDS and CHICA; most importantly
migration data (place of residence, and in- and out-migration events) but also
household characteristics (family constitution, poverty, education,
employment). The sample drawn for the second step of the survey was
nevertheless based only on migration data (besides age, and the data
concerning health problems from our initial questions).
The study population and the sample frame
Before making the sample, we first excluded those who were younger than 17
years (since the study was to focus on adults). The study population was
successively categorized according to migration experience (Non-mover/Leftbehind/In-migrant54) and individual health status (Healthy/Chronic
ill/Other ill55). The categories were strictly defined, in the sense that a person
could not share characteristics with someone in another category of the same
type (e.g. both Non-mover and Left-behind). Through combining these
migration and health categories, nine different sample groups56 were created.
The sample frame that was ultimately created consisted of 19,058 women and
men (47% of the respondents of our 2007 survey) (Table 2, next page). A total
of 5,350 individuals resided in León (equalling 10% of the HDSS population,
and 41% of the 2007 respondents), and 13,708 lived in Cuatro Santos (51% of
the HDSS population). As seen in the table below, most individuals in the
sample frame were Non-movers (sample groups 1 a-c) or Left-behinds
(sample groups 2 a-c). A small share were In-migrants (sample groups 3 a-c),
of which the majority lived in Cuatro Santos. Moreover, those classified as
54 Non-mover: person who still lived in his/her place of birth; no migration history in the family; Left-behind:
family member of out-migrant; no personal migration history; In-migrant: person who had moved into the
household from another place, no record of out-migration.
55 Healthy: person who reported no health problems; Chronic ill: person who reported at least one chronic
health problem; Other ill: person who reported at least one acute/other health problem (not chronic).
56 The nine sample groups were thus the following:
1a. Non-mover, healthy; 1b. Non-mover, chronic ill; 1c. Non-mover, other ill.
2a. Left-behind, healthy; 2b. Left-behind, chronic ill; 2c. Left-behind, other ill.
3a. In-migrant, healthy; 3b. In-migrant, chronic ill; 3c. In-migrant, other ill.
71
Healthy far outnumbered those who were categoriezed as Chronic ill or Other
ill; especially the Chronic ill were few.
Table 2: The study population and sample frame
HDSSa
Survey 2007 (Step 1)b
Sample framec
León
Cuatro Santos
Total
56,0001
24,5682
13,171 (24)
5,350 (41)
27,142 (100)
13,708 (51)
80,568
40,313 (50)
19,058 (47)
3,527 (66)
177 (3)
585 (11)
811 (15)
27 (0.5)
61 (1)
145 (3)
5 (0)
12 (0)
5,948 (43)
420 (3)
1,139 (8)
4,696 (34)
248 (2)
466 (3)
698 (5)
15 (0)
78 (0)
9,475 (50)
597 (3)
1,724 (9)
5,507 (29)
275 (1)
527 (3)
843 (4)
20 (0)
90 (0)
Sample groupd
1a. Non-mover, healthy
1b. Non-mover, chronic ill
1c. Non-mover, other ill
2a. Left-behind, healthy
2b. Left-behind, chronic ill
2c. Left-behind, other ill
3a. In-migrant, healthy
3b. In-migrant, chronic ill
3c. In-migrant, other ill
Notes: a) individuals monitored in the Health and Demographic Surveillance Systems (HDSS);
b) participants in Step 1 of our survey (2007); c) individuals in the sample frame; d) sampled
individuals according to sample group; 1) year 2008; 2) year 2007 (the number of inhabitants
was, as seen in the table, larger when we conducted the survey). In absolute numbers and
percentages (in parentheses).
The final sample
Due to time and budget restrictions, we limited our sample to 250 individuals
per sample group (125 per study setting). However, since some sample groups
did not include such a high number of individuals (e.g. group 2b in León, and
3b in both study settings; see Table 2), we could not select the sample in these
groups randomly. Consequently, all individuals in these groups were selected
so as to make the groups as large as possible, and as similar in size as the
others (and, large enough to provide sound/significant results in the
analyses). Furthermore, in order for the group of In-migrants to be large
enough in León, we had to over-sample those in-migrants categorized as
Healthy (sample group 3a; see Table 2). In the forthcoming analyses we have
weighted the sample groups according to their original sizes, in order not to
make the results skewed (see Table 6, p. 80, for the calculations of weights).
72
Our sample ultimately amounted to 1,718 individuals57 (Table 3). The
distribution, in terms of responses/non-responses, place of residence, sex and
sample group, is presented in the table below.
Table 3: The sample.
All
Total sample
Sample size
Females
Respondents
Non-responses
Sample group
n.
1718
1002
1383
335
%
100
58
81
19
1. Non-mover
a) healthy
b) chronic ill
c) other ill
2. Left-behind
a) healthy
b) chronic ill
c) other ill
3. In-migrant
a) healthy
b) chronic ill
c) other ill
“Health status” group
750
250
250
250
588
250
152
186
380
270
20
90
44
Healthy (1a, 2a, 3a)
Chronic ill (1b, 2b, 3b)
Other ill (1c, 2c, 3c)
770
422
526
45
24
31
34
22
León
n.
750
441
572
178
375
125
125
125
213
125
27
61
162
145
5
12
395
157
198
%
44
59
41
24
50
28
22
53
21
26
Cuatro Santos
n.
%
968
56
561
58
811
59
157
16
375
125
125
125
375
125
125
125
218
125
15
78
39
375
265
328
39
27
34
39
22
Notes: In absolute numbers and percentages.
As seen, 335 of the sampled individuals did not participate in the survey; the
respondents thus amounted to 1,383 persons, and the non-response rate
equalled 19%. The sizes of the sub-groups in the sample varied, ranging from
22% to 45%58. There were more individuals in the categories Non-mover
(44%) and Healthy (45%), and fewer in the categories In-migrant and
Chronic ill (22% and 24%, respectively). The shares of Left-behind and Other
ill were between 31% and 34% (thus close to the expected value of 33%). There
were, furthermore, differences in the sample regarding the two study areas. A
larger share of the sampled individuals lived in Cuatro Santos (56%). The León
sample included more individuals in the categories Non-mover and Healthy,
whereas the sample in Cuatro Santos included more in Left-behind, Chronic
57 The total number of household members whose background data were included in the sample construction,
and who therefore serve as a base in the forthcoming analyses, amounted to 7,188.
58 For equal distribution, each group should be 33.3%.
73
ill and Other ill. There was also a slight gender bias in the sample (58-59%
were women).
The questionnaire
The work of constructing the questionnaire for the survey in Step 2 began
during my third visit to Nicaragua, with a first draft based on findings from
the qualitative interviews and on other previous research, and then continued
at home in Sweden with discussions with research colleagues at the Division
of Epidemiology and Public Health at Umeå University. During the fourth
period of fieldwork, in March-April 2008, much time was initially devoted to
discussing the content of the questionnaire with researchers and other staff
members at CIDS and CHICA, who then tested it on family members and
friends. I also personally tested it on a couple of people in my surroundings.
Various changes were made before the questionnaire was finally piloted in the
HDSS population, using approximately 15-20 people in León. In the end, the
questionnaire included a mix of questions stemming from theories, previous
studies, and results from the interview study, concerning the following issues
(see Appendix for the full version):







Migration (personal experience of migration, and migration of
significant others)
Self-rated and self-reported health
Use of health services and medicine
Access to social security
Social support (material and emotional help from/to significant
others within the person’s social network)
Social integration and participation
Life situation and legal status of significant others living abroad
After the pilot was finished, along with the fieldwork teams at CIDS and
CHICA, respectively, I drafted lists of the names and addresses of the selected
individuals, which would be used during the fieldwork. With help from CIDS’
GIS technician, Margarita Chévez, maps of the León area were designed,
marking the selected houses. The fieldworkers were also recruited at this
point, based on their earlier experience working with the demographic and
health surveys. Four women in León and 12 women in Cuatro Santos were
employed, and divided into teams with appointed work areas. Just before the
fieldwork started I held a one- or two-day workshop with the fieldworkers at
both locations, along with those in charge of the fieldwork (Aleyda Fuentes at
CIDS and Francisca Trujillo at CHICA), so that the fieldworkers would
understand the purpose of the study, and could practice how to ask the
74
questions and fill out the questionnaire. When this was done, I had at long last
received ethical clearance from León University (see p. 62); the survey round
could finally start.
The survey procedure
Our survey followed the same, well-developed procedure as all HDSS surveys
generally do. The questionnaires were conducted face-to-face between the
fieldworkers and the respondents. In the first step of our study, just as in other
HDSS rounds, the respondent was typically the head of household, or, if
he/she was absent, anyone in the household aged over 16 years. In the second
part of our study, the respondent was the individual selected in the sampling
process. The fieldworkers were led, and coached by, a team supervisor
responsible for the data collection. Shortly after the questionnaires had been
finalized they were handed over to those in charge at both offices, who then
controlled the quality. Every week, one or two questionnaires per fieldworker
were randomly chosen for an additional quality control, in which the office
staff returned to the selected household to re-do the questionnaire and
thereafter compare the answers to check whether any mistakes had been
made. The information from the questionnaires was then entered in databases
by the data units at both offices. Lastly, the questionnaires were filed and
stored at both offices (see Peña et al. 2008, for further information about the
working procedure). Of the 1,718 sampled individuals, 1,383 completed the
questionnaire: 572 in León and 811 in Cuatro Santos. The whole survey
procedure is visualized in Figure 5, below.
HDSS, 2007
L: 13,000 h
56,000 i
CS: 4,828 h
24,568 i
Step 1, 2007
Step 2, 2008
L: 2,500 h
13,171 i
CS: 5,000 h
27,142 i
L: 750 i
CS: 968 i
Final
responses
L: 572 i
CS: 811 i
Figure 5: The two-step survey.
HDSS = Health and Demographic Surveillance System,
L = León, CS = Cuatro Santos, h = households, i = individuals.
An HDSS round normally takes about three months to complete. Our survey
in León took about this long, but in Cuatro Santos the work was delayed
because of heavy rains. Unfortunately, I only had the possibility to participate
during the first days of the fieldwork, in May 2008. Upon my return to
75
Sweden, I stayed in close contact with the staff at CIDS and CHICA over the
Internet, in order to be available if problems arose and to follow their progress.
A couple of months after my return to Sweden I received the results of the
survey study in the form of Access databases, sent via e-mail from the data
units at CIDS and CHICA, respectively.
Fieldwork, Cuatro Santos. Photos: Mariela Contreras.
76
The final result
Thus, 1,383 individuals responded to the survey, which gives a response rate
of 81% on average (76% in León and 84% in Cuatro Santos). A higher number
of respondents resided in Cuatro Santos than León (811/572), yet about the
same number lived in urban and rural areas, respectively (697/686) (there
were no rural respondents in León due to the selection) (Table 4).
Table 4: The respondents.
Urban/Rural
Female/Male
Mean age (years)
Sample group
Non-mover
Left-behind
In-migrant
Healthy
Chronic ill
Acute/other ill
Relation to HoH (missing)
Head of household (HoH)
Spouse
Child (adult child)
Other family
Non-family
Education
(missing)
No/very low education
Low education
Medium education
High education
Not appl. (education)
Occupation
(missing)
Housewife
Non-skilled worker
Skilled worker
Highly skilled worker
Informal worker
Student
Unemployed
Not EAP
Poverty
(missing)
Not poor
Poor
Extremely poor
All (n 1,383)
León (n 572)
CS (n 811)
697/686
832/551
44.5
572/0
350/222
42.6
125/686
482/329
45.8
672
462
249
524
367
492
335
144
93
222
168
182
337
318
156
302
199
310
(1)
(0)
(1)
563
369
304
134
12
222
133
150
64
3
341
236
154
70
9
(40)
(0)
(40)
275
594
358
109
7
71
193
203
102
3
204
401
155
7
4
(52)
(15)
(37)
480
251
195
91
56
89
46
123
110
18
168
61
46
61
40
53
370
233
27
30
10
28
6
70
(47)
(42)
(5)
522
748
66
328
174
28
194
574
38
Notes: All data except on sample groups are derived from the HDSS. In absolute numbers
(unweighted values).
77
Analysis of non-responses
The reason for non-response was only noted in Cuatro Santos, where the main
reason was that the fieldworkers were unable to contact the respondent, most
commonly due to emigration and, to a lesser extent, absence from home (13
of the sampled individuals had died). The non-response rate was higher in
León than Cuatro Santos (24 and 16% of the respective samples). Most nonresponses were found in sample groups 3a and 2a (i.e. In-migrant, healthy
and Left-behind, healthy), together accounting for more than half of all nonresponses. Nearly half (48%) of the sampled individuals who did not
participate in the survey were heads of household or spouses of heads of
household (28 and 20%, respectively). A third were categorized as children
(i.e. in relation to head of household), and 16% were counted as “other family”
(e.g. grandparents and aunts). There was no great gender difference
concerning the non-response-rate (51% females, 49% males).
The survey data and statistical analysis
As mentioned earlier in the text, the HDSS data collected at both study sites
since the first survey rounds began (in 2002 in León and in 2004 in Cuatro
Santos) comprise information on socio-economic conditions, demographic
events, and reproductive and child health. The HDSS data we have used in our
study are from the years 2002-2007 (2004-2007 for Cuatro Santos); and we
have, furthermore, exclusively used data on socio-economic conditions and
vital events. These data have served two purposes in the present study: the
data on migration events were used as background information in the sample
process; and both the data on socio-economic conditions and on vital events
(particularly migration events) were used as background information in the
analysis of the 2008 survey – more specifically, for examining the
characteristics of the respondents and of their respective household members.
The HDSS data thus served as background information in both the sample
process and the analysis of the 2008 survey. The additional information we
retrieved through the first step of our survey in 2007 also served as
background in the sample process, but it has also been used as analytical
material. Together, these two sources have been used in the analysis of the
data from the 2008 survey. In Table 5 (next page), all data we have used in the
forthcoming analysis are presented: the HDSS data, as well as the data from
the first and second steps of our survey.
78
Table 5: Variables in the data
Data
Demographic
Socio-economic
Health
-Education (i)
-Occupation (i)
-Poverty index (h)
-Births (i)
-Deaths (i)
HDSS,
20022007
-Age (i)
-Sex (i)
-Family (i,h)
-Place of residence (i)
-Event history (i)
-Migration: type &
reason (i)
-Reception of
remittances (h)
-Health problems in the
past three months (i)
-Health service use (i)
-Health problems in the
past three months
-Use of health services
-Use of medicine
-Self-rated health
(physical and mental)
Step 1,
2007
-Migration history
-Family network
-Legal status of
emigrated family
members
Step 2,
2008
-Social insurance
coverage
-Help from others
-Help from others
during sick period
-Help, provision to
others
-Contact with family
members in other
places
-Social participation
-Social integration
Attitudes
-Migration
intention
-Satisfaction
with health
services
-Perceived social
support
-Perceived life
situation for
emigrants
Notes: The unit for data collection is marked “i” for individual and “h” for household for the HDSS data and
Step 1 of our survey, though not for the 2008 survey since those data are individual.
It is perhaps necessary to point out once again that the HDSS surveys are
conducted with the head of household, or if he/she is unavailable, anyone at
home aged 16 years or over. Consequently, a high degree of the HDSS data is
“second-hand” information, provided by one (or a few) members of the
household. This implies that the information about out-migration is always
provided by the family members who are left behind rather than by the
migrant him/herself. In the present study, this applies to the HDSS data we
have used as background information, and to the data concerning health
problems and remittances we retrieved through our additional questions in
the first step of our survey in 2007. The data from our 2008 survey, in
contrast, were collected directly from the sampled individual.
Definitions in the HDSS data
“Household” is defined in the HDSS as all persons sleeping under the same
roof for at least half of the past month. “Housing conditions” are defined
according the house’s structure of walls, floors and roofs, and the type of water
supply, kitchen, and toilet/latrine. The level of poverty, calculated according
to the Unsatisfied Basic Needs Assessment, is based on three factors: housing
conditions (see above), school enrolment, and dependency ratio and
educational level of the head of household. If a household experiences twothree unmet basic needs in these three areas it is categorized as poor, and if
79
four needs are unmet it is considered extremely poor. In the HDSS data, a
“resident” is someone who has lived in the same household since baseline.
“Out-migration” refers to a person having moved out of the household at least
six months prior to the visit, whereas “in-migration” refers to the opposite – a
person having moved into the household within the past six months (Peña et
al. 2008).
Analysis of the survey data
As mentioned in the above description of the survey design, some sample
groups were over-sampled in the sample process. Due to this, weights had to
be applied to each sample group before the analyses could be performed
(Table 6).
Table 6: Weights
Sample frame (n)
Sample group
1a. Non-mover, healthy
1b. Non-mover, chronic ill
1c. Non-mover, other ill
2a. Lef- behind, healthy
2b. Left-behind, chronic ill
2c. Left-behind, other ill
3a. In-migrant, healthy
3b. In-migrant, chronic ill
3c. In-migrant, other ill
León
3,527
177
585
811
27
61
145
5
12
CS
5,948
420
1,139
4,696
248
466
698
15
78
Sample (n)
León
125
125
125
125
27
61
145
5
12
CS
125
125
125
125
125
125
125
15
78
Weight
León
28.2
1.4
4.7
6.5
1.0
1.0
1.0
1.0
1.0
CS
47.6
3.4
9.1
37.6
2.0
3.7
5.6
1.0
1.0
Notes: The calculation of weights for each sample group is based on the number of individuals
(n) in the sample frame and in the sample, for each study setting separately (CS=Cuatro Santos).
In order to take into account the appropriate weights of the different sample
groups in the analysis, I used the programme IBM SPSS Complex Samples59.
The main methods for analysing the survey data thereafter consisted of
descriptive statistics (frequencies and cross tables) and binary logistic
regression analysis. The aim of the regressions was, first, to take the
descriptive analysis a step further by looking at what characterized certain
groups in the material (e.g. remittance-receivers), and, second, to explore
associations between migration categories (Non-movers, Left-behinds, and
In-migrants) and socio-economic characteristics and health indicators (e.g.
self-reported illnesses and self-rated health). The regression analyses are
explained more thoroughly in the empirical chapters (Chapters 5 & 7).
59 See: http://public.dhe.ibm.com/common/ssi/ecm/en/ytd03116usen/YTD03116USEN.PDF, for further
information about this programme.
80
The last fieldtrip: feedback and follow-up
In November 2013 I made a final fieldtrip to Nicaragua, with the ambition to
present and discuss the findings of the qualitative and quantitative studies. I
also aimed to follow up the interviewees who had participated in the
qualitative part of the study. During the trip, I held three presentations for
different audiences in León and in Matagalpa60, which all ended with a
discussion session that brought up many relevant questions and comments. I
unfortunately did not manage to present the study in Cuatro Santos, but our
collaborators from the area (those who currently or in the past had worked at
CHICA) nevertheless attended our presentations in León. Besides the more
formal presentations, we also discussed the study findings with researchers at
CIDS and CHICA as well as those more practically involved with the survey
(the responsible fieldworkers and database technicians), who also
participated in our seminars in León. Moreover, I also followed up how life
now was for some of my interviewees. I personally talked to three of them
(Cesar, Marta and Rosa), and through acquaintances (those who had
introduced me to the respective person) I heard how three more interviewees
were doing (Ana, Maribel and Mercedes).
Reflections on conducting mixed-methods research
In this study I have used both qualitative and quantitative methods because I
wished to investigate both the in-depth and the general picture of migrationhealth relations in Nicaragua. The mixing of methods has taken place
throughout the research project; from the initial data collection to the
analysis, and in the presentation and discussion of the study findings. I have
not followed a particular strategy for conducting mixed-methods research
wholly or exclusively, but triangulation, complementarity, bricolage and
pragmatism have all been inspirational. I have perhaps seen the qualitative
and quantitative data more as complementing than validating each other, but
I have also looked at convergencies between the two types of data (for
example, whether or not a certain issue could be found in the other type of
data). I have had a rather pragmatic outlook throughout the research process,
and focused more on conducting the research and finding answers to the
research questions than on thinking about ontological and epistemological
matters (for example, I have not used only one type of literature to
60 I made the presentations together with Gunnar Malmberg, as part of a programme established by a
Nicaraguan-Swedish research team consisting of Mariano Salazar and Ann Öhman from the Division of
Epidemiology and Public Health, Umeå University. Two presentations were held in León for students,
researchers, fieldworkers, and university staff (e.g. the Dean of the Medical Faculty). One presentation was held
in Matagalpa for people involved in the NGOs Grupo Venancia (a feminist network) and Médicos del Mundo
(Doctors without Borders, Matagalpa section). Approximately 150 people in all listened to the presentations.
81
contextualize my findings, and I have switched between posing qualitative and
quantitative research questions). In this sense I have perhaps served as some
sort of quilt maker (bricoleur).
Personally, I have not experienced any major problems of a paradigmatic kind
in the mixed-methods research process; largely since I do not regard myself
as belonging to a paradigmatic “extreme”. Instead, I share the realist
ontological view (meaning that reality has an existence independent of human
apprehension), and the subjectivist epistemological view (meaning that the
knowledge we have about reality is always “coloured”, or subjectively
influenced). Understanding is interpretation, as the hermeneutic tradition
proclaims (Schwandt 2003). I have also been inspired by critical
hermeneutics, which “brings the concrete, the parts, the particular into focus,
but in a manner that grounds them contextually in a larger understanding of
the social forces, the whole, the abstract (the general)” (Kincheloe & McLaren
2003: 445). Therefore, I have found it crucial to place the observations I made
in the field – by means of the interviews and the survey – in their social,
cultural and historical contexts. Moreover, I believe that this context is shaped
by power relations; hence, in line with some critical theorists I “locate the
foundations of truth in specific historical, economic, racial and social
infrastructures of oppression, injustice, and marginalization” (Lincoln & Guba
2003: 272-273).
The mixing of methods has been conducted from somewhere between a
pragmatic “middle stance” and a qualitative perspective. However, my belief
that knowledge about reality is produced/created in the interplay between
myself as an academic and my interviewees/respondents, and that this
knowledge is always subjectively “coloured” (situated) (Riessman 2008),
makes a high degree of reflexivity necessary during the whole research
process. I have consequently paid attention to both my own and my research
participants’ embeddedness in various value systems, and reflected upon
identity formations, biases and prejudices, and how these may have
influenced the research process. During the writing process, I have also tried
to be as self-reflexive as possible, and it is for this reason I write in the first
person; emphasizing that these are my words and my interpretations. The way
I have looked upon myself as a researcher, and upon the whole research
process (the collection, analysis, and interpretation of empirical material) has
been the same regardless of which method I have employed (see Lawson
1995). Hence, in this line of reasoning, the findings stemming from the
empirical material should be regarded as providing only partial and
incomplete pictures from reality, and the thesis as a whole should be regarded
as an interpretative account of the information and the stories collected
through the qualitative and quantitative research methodologies.
82
The use of a mixed-methods approach proved to be of great value for a
comprehensive understanding of migration-health relations in the study
setting. The interviews allowed the connections between migration and health
to be explored with an open mind, and provided a personal and contextualized
understanding of the complex ways migration and health are connected in the
case of Nicaragua. The survey made it possible to investigate the size and
scope of certain aspects of migration-health relations, and this data thus
provided general descriptions as well as information on certain associations
between migration and health. Hence, the two methods have complemented
each other in important ways through generating different kinds of
knowledge, aiming at depth and breadth, understanding and generalization.
Even though I did not experience any major paradigmatic difficulties, I did
have some problems related to my ability to conduct quantitative research,
since I had mainly worked with qualitative studies before this. The
quantitative survey study proved to be time-consuming, both in the collection
phase and in the analytical work. I also experienced some difficulties
concerning how to best present the results from the interview and survey data
without placing emphasis on one over the other.
The next chapter provides a background of the study context – Nicaragua – in
both past and present times. It also presents the two study settings, León and
Cuatro Santos, in more detail.
Mural, central León.
83
Church of Subtiava, León.
Street view, León.
84
CHAPTER FOUR
Nicaraguan landscapes:
“La vida es dura”
A common saying in Nicaragua is “la vida es dura”, which in English
translates to “life is hard”. This phrase captures a great deal of how life is
experienced by the Nicaraguan people61. The men and women I interviewed
for this study all mentioned the difficult living conditions in Nicaragua, in
relation to various areas such as the economy, the labour market, politics,
migration, the educational and health care systems, and the unpredictable
nature conditions. I believe it is essential to acknowledge this context for a
proper analysis and understanding of the migration-health nexus in the case
of Nicaragua. The main objective of this chapter is therefore to provide an
account of relevant aspects of this context, mainly through the use of
secondary sources. Some quotations from the interviews are also included to
illustrate the events portrayed.
The chapter starts off with a historical exposé of crucial moments in the
history of Nicaragua in relation to Central America as a whole. It begins in the
colonial era and the period after independence, and continues with the years
of dictatorship, revolution, the Contra war and structural adjustments.
Thereafter follows a description of present-day Nicaragua, with focus on the
political, social and economic situation at the time of the fieldwork, when
former revolutionary leader Daniel Ortega came back into power. The central
issues of migration and health in Nicaraguan society are portrayed throughout
the chapter. An overview of key events and selected socio-economic indicators
is presented in Table 7, p. 122.
Nicaragua has been damaged by many things…
Earthquakes… and bad governments, above all.
(Fernando, 50 years, Cuatro Santos)
61 Robert Lancaster portrays this saying in his book “Life is hard: Machismo, Danger and the Intimacy of Power
in Nicaragua” (1992).
85
Crucial
moments
in
the
transformations 1520-2006
past:
socio-economic
“From the violence […] emerged Nicaragua”, wrote the American historian
Bradford Burns in 1991 (Burns 1991: 1). This quote highlights the conflictridden nature of Nicaraguan society after it gained independence from
colonial rule. The social, political and economic imbalances that began during
the colonial era came to characterize Nicaragua in the post-independence
period as well, and have continued to distinguish the country ever since, as we
shall see in this chapter.
Because of a “shared geopolitical destiny” (Torres Rivas 1993: xvii) with the
rest of Central America, I will portray Nicaragua’s history in relation to the
whole isthmus (although important differences between the five countries
there do exist, which have caused them to develop differently over the years)
(Walker & Wade 2009; Cardoso 1985). Nevertheless, Nicaragua and all
Central American countries except Costa Rica share the historical similarities
of externally oriented agricultural economies, patterns of dependency and
elite rule that took root under the colonial period and continue today, and that
have led to stagnated economies with little prospect for socio-economic
development (Torres Rivas 1993; Walker & Wade 2009, 2011). In the case of
Nicaragua, its economic history before the 1979 Sandinista revolution can be
divided into four periods: the colonial period (1520-1820), the first 50 years
after independence (1820-1870), the period of primitive dependent capitalism
(1870-1950), and, lastly, the rise of modern dependent capitalism (1950-1979)
(Walker & Wade 2011). The revolutionary years with “leftist”/“socialist” ideas
for development then followed (1979-1990), after which the “neo-liberal”
period came about (1990-2006). During my fieldwork period – which will be
discussed later in the chapter – a new “socialist” period had gained
momentum.
Contemporary Nicaraguan migration patterns are largely connected to the
economic processes described above; which, furthermore, have taken place
under centuries of regionalization and mutual interdependence between the
countries of Central America. It is possible to discern three main phases of
Central American migration during the 1900s, which are relevant for
understanding the migration patterns in Nicaragua today (Morales & Castro
2002, 2006; Castillo 2001). The first phase was enacted in relation to the
“modernization” of agriculture that began in the 1950s, as a continuation of
the agro-export process that started in colonial times, during which the
number of agricultural migrant workers – as well as rural-urban migrants –
in the region increased. The second phase took place in the 1970s and 80s in
relation to the armed conflicts and civil war in several Central American
86
countries (Nicaragua, El Salvador and Guatemala), and the economic
consequences thereof, which produced a vast number62 of refugees and
internally displaced persons in the entire region. The third phase has been
underway since the late 1980s, and is characterized by the insertion of local
economies into the “global” economy, which has transformed the labour
markets in the whole of Central America, with increasing migration into cities
for predominantly informal job opportunities, and international migration to
labour markets abroad. In Nicaragua, migration has thus gone from being
mostly an internal and regional matter to an increasingly international
process. The motivations for migration have, furthermore, been influenced by
a mix of economic, political and socio-cultural factors. The economic and
migration processes outlined above will be further described in the coming
pages, along with socio-demographic and political issues of importance for
understanding today’s Nicaragua.
The colonial era and the post-independence period
For about 300 years, between the 1520s and the 1820s, Nicaragua was – as
part of the kingdom of Guatemala – colonized by Spain. The early years of
colonization had deep and long-lasting socio-economic and political
consequences for the country. Before the Spanish arrived Nicaragua was a
feudal society, but land was collectively owned and every inhabitant had
access to it. The economy, based on agriculture and trade, was relatively selfsufficient and self-contained, and generally satisfied the people’s basic needs.
Just a few decades after Spain had colonized the area, however, the
agricultural base had been destroyed, primarily because of the decimation of
the indigenous population due to killings, disease and slavery; only about 8%
of the indigenous population survived the conquest (approximately 3060,000 individuals of the original 825,000-1 million inhabitants) (Lovell and
Lutz 1991/1992). This genocide had profound social effects; since then, the
majority of the population are mestizo and Spanish-speaking (Walker & Wade
2011; Staten 2010; Morales & Castro 2006). Seventeen years after
independence from Spain, in 1838, Nicaragua became an independent
country when it broke free from the United Provinces of Central America,
which had been created when Spain had left. But foreign dominance
continued even after independence as Britain held the Eastern parts of
Nicaragua, the Mosquito Coast, as a protectorate on and off until the 1900s
(Walker & Wade 2011; Staten 2010; Pastor 1987).
62 No exact numbers exist; estimates range between 129,000 (UNHCR) and 2 million (Mármora 1996)
(referred to by Morales & Castro 2006).
87
Spanish colonial interests in Central America centred on mining and
agriculture. The geographical, demographical and social differences between
the countries of the isthmus made Spanish colonial interests higher in
Guatemala and El Salvador than in Nicaragua and Costa Rica. Because of
Spain’s weak interest in Nicaragua, the country did not achieve an agrarian
export economy like many of the other Central American countries (Torres
Rivas 1993). Some land in Nicaragua continued to be cultivated (for the export
of corn and cacao and for local consumption), but for the most part
agricultural lands either grew wild or were used for cattle raising (for the
export of cattle products). All exploitation by the Spanish thus served external
rather than internal demands (Walker & Wade 2011). Indigo and cochineal
were other important export crops at that time, and their cultivation
transformed the productive infrastructure of several Central American
countries, including Nicaragua, into one of haciendas (privately-owned smallto medium-sized farms) and obrajes (workshops) that to some extent relied
on a coerced labour force of indigenous campesinos (peasants). Before this,
peonage had been unheard of in Nicaragua, in contrast to Mexico and other
South American countries (Torres Rivas 1993; Wolfe 2004). Today’s seasonal
labour migrations in the region can be seen as a legacy of this socio-economic
transformation (Torres Rivas 1993; Morales & Castro 2006).
The production and export of coffee rose significantly in importance in Central
America in the last decades of the 19th century. In Nicaragua, coffee became
important after 1870, and a coffee agro-export began forming at the beginning
of the 20th century. Nicaragua never came to produce more than 10% of the
Central American volume, however (Torres Rivas 1993), partly because it was
competing with the traditionally dominant economic activity of cattle raising
(Cardoso 1985). In the largest coffee-producing countries, a new productive
organizational structure and new forms of land tenancy took form, which
produced a coffee bourgeoisie that controlled national politics (Torres Rivas
1993). The socio-economic structure in Nicaragua also changed as coffee
production grew in the latter half of the 19th century. Agricultural laws were
passed in order to control the land and the labour force; wealthier
Nicaraguans migrated to the fertile lands, and private smallholdings became
the norm. A growing share of the population was forced to become seasonal
day labourers (jornaleros) in order to make a living. In the northern
highlands, many peasants and indigenous farmers lost their land and had to
accept the work offered by the new, larger coffee plantations (Walker & Wade
2011; Staten 2010; Wolfe 2004; Revels 2000; Morales & Castro 2006).
Foreign immigration was also encouraged through tax reforms, and a number
of wealthy Germans, British and Americans settled in the north-central
regions to become coffee growers (Revels 2000). Nicaragua was, thus – like
the rest of the countries in Central America in the colonial period – a country
88
that attracted immigration, rather than one of emigration (Morales & Castro
2006). The expansion of coffee production – and later of cotton production –
was particularly focused in the fertile Pacific and Central regions of Nicaragua,
which led to the displacement of peasants from these areas. Many moved to
the north-central regions (e.g. Jinotega and Nueva Segovia), or to frontier
regions (e.g. San Juan and Zelaya). Growing areas of capitalist agriculture, for
instance the region of the capital Managua, as well as León and Chinandega,
attracted in-migrants at the time (Hamilton & Chinchilla 1991). By the end of
the 1800s, coffee had become the main export product of Nicaragua, and it
continued to be an important part of the country’s economy until the 1950s
(Staten 2010). Despite this, it did not serve as a base for socio-economic
development for the country as a whole since the profits mostly went to the
Nicaraguan elite. Moreover, due to periodic booms and busts the economy
fluctuated constantly (Walker & Wade 2011).
Besides coffee, Nicaragua – as well as Honduras – exported larger amounts of
gold and silver during this period. However, due to foreign (i.e. English and
American) ownership, this production did little for the country’s economic
development. Thus, Nicaragua never consolidated a national economic base
and favourable conditions for economic development during this era, but it
also did not develop a monoculture system, as did Costa Rica, Guatemala and
El Salvador, that displaced subsistence agriculture activities and provoked
crisis in the national food supplies when coffee prices began falling at the turn
of the century (Cardoso 1985; Torres Rivas 1993). Thus, a specific trait of
Nicaragua at the time was the combination of fragmented exploitation and
subsistence agriculture.
Banana plantations entered the Central American productive scene towards
the end of the 19th century, and grew in importance in the first decades of the
1900s as the United Fruit Company expanded its holdings across Central
America. Banana production never stabilized in Nicaragua, however; it was
only a big cash crop between the 1920s and 30s. Just like the mines, banana
plantations were enclave economies and had little effect on the national
economies of the various countries (Torres Rivas 1993). The banana
production, like the coffee cultivation, led to high flows of internal migrations
within Central America. People resettled in the plantation areas, and many
also migrated temporarily for the harvest seasons. The banana plantations in
Honduras and Costa Rica, for instance, attracted a steady flow of migrant
workers from El Salvador and Nicaragua (Cardoso 1985).
The social and administrative system introduced during colonization,
whereby a minority of whites and creoles/mestizos governed the economic
and political life, led to high instability in the region after independence.
89
Political chaos characterized Nicaragua from the end of colonial rule until the
middle of the 1850s. Before 1858 there were no strong political leaders, in
comparison with the rest of Latin America where so-called caudillos
(“strongmen”) emerged as leaders (Burns 1991). Nicaragua, just like
Honduras, suffered a great deal because of internal conflicts and civil war,
compared to the other Central American nations (Torres Rivas 1993; Anna
1985; Woodward 1985). The most tangible conflict in Nicaragua – which
began developing already in the early phases of colonization – stood between
the Liberals in the town of León and the Conservatives in the city of Granada,
who fought over the power to decide over the nation’s future, sometimes
backed by allies in other Central American countries (Walker & Wade 2011;
Torres Rivas 1993; Burns 1991; Anna 1985; Woodward 1985).
The foreign dominance over Central America that had begun in the colonial
period continued in the post-independence era. Control was long sought over
the transit routes for trade across the isthmus, and several countries competed
for the construction of an inter-oceanic canal connecting the Caribbean to the
Pacific Ocean. Nicaragua was particularly affected by this struggle due to its
geographical position, and also saw intrusions into its internal politics as a
result (Walker & Wade 2009, 2011; Staten 2010; Torres Rivas 1993;
Woodward 1985; Freeman Smith 1985). The United States’ interest in the
trade routes grew around 1850, when gold was found in California. Towards
the end of the 19th century, the US excluded the British from the area (which
also expelled Britain from the Nicaraguan Mosquito Coast) and gained
exclusive rights to any isthmian canal. Later, when it was decided that Panama
would be the site for this canal, the US-Nicaraguan relationship deteriorated
and the US interest focused on maintaining political stability in the region in
order to gain access to the Panama Canal (Staten 2010; Pastor 1987). As a
result of this strategic interest in Nicaragua, beginning in the second half of
the 1800s several intrusions by the US took place. In 1855, the American
“soldier of fortune” William Walker arrived in Nicaragua with a small armed
force (despite dissuasion by the US government, according to Pastor 1987),
and successively assumed power along with the Liberals. This takeover was
not appreciated by the Nicaraguans, nor by the British or other Central
Americans, and after two years of civil unrest the US arranged a truce and let
Walker surrender (Walker & Wade 2011; Staten 2010). The struggle against
Walker was costly to the weak national economy, in terms of both human lives
and money (Torres Rivas 1993).
Three decades of political peace and Conservative dictatorships then followed
before the Liberals, headed by President Zelaya, seized power in 1893 (Walker
& Wade 2011; Staten 2010; Torres Rivas 1993). Zelaya made some significant
contributions to the socio-economic transformation of Nicaragua (e.g.
90
development of infrastructure); however, due to conflicts with American
interests he was overthrown in 1909 by the US-supported Conservatives
(Walker & Wade 2011; Staten 2010; Cardoso 1985). Some years later, the US
Marines became permanently stationed in Nicaragua, with the aim to control
internal affairs in favour of the Conservatives; an occupation that came to last
about 20 years (between 1912 and 1933, except for nine months in 1925-26).
Although a guerrilla war – under the lead of Liberal General Sandino – was
waged against the Conservative government and the US-supported National
Guard, it was rather changes in American foreign policy that influenced the
US Marines to leave Nicaragua in 1933. Robert A. Pastor (1987), professor in
political science and director from 1977 to 1981 of Latin American and
Caribbean Affairs on the American National Security Council, states that the
US actions in Nicaragua during the first three decades of the 20th century were
primarily driven by strategic concerns regarding the Canal. However, also
according to Pastor, the US interventions were initially not meant to last as
long as they did. When the Americans left, the leader of the National Guard –
Anastasio Somoza García – assumed power along with a new Conservative
government (Walker & Wade 2011; Staten 2010; Cardoso 1985).
The Somoza dynasty and the Sandinista revolution
General Anastasio Somoza García, leader of the National Guard, became
President in 1936 after a staged election. The Somoza family’s dictatorship
came to last over 40 years; a governance characterized by brutal repression of
the opposition, as well as vast corruption within the elite (Walker & Wade
2009, 2011; Sangmpam 1995; Pastor 1987). For “survival”, the Somozas had
to rely on support from three main actors: the National Guard, the economic
elite, and the US. In order to achieve loyalty the Guardsmen was allowed to
conduct illicit business, and they became vastly corrupt. The economic elite
received tax exemptions, attractive loans and government contracts. The
Somozas – many of whom had received an American education – were strong
supporters of US foreign policy and consequently received both financial and
military support from the US in return (Staten 2010; Walker & Wade 2011).
During the Somoza years, Nicaragua’s production base underwent important
changes. The country’s exports became diversified to include coffee, beef,
sugar, bananas, wood, seafood, and most importantly cotton, which became
the country’s largest export product around 1955 (Walker & Wade 2011;
Staten 2010; Spalding 1994). Meanwhile, the country became more
dependent on the US, which imported more than 90% of Nicaragua’s exports
(Staten 2010). Cotton production was a capital- and land-intensive business
that required great investments in machinery, fertilizers, insecticides, and
91
labour. As a result of this production, a basic infrastructure was developed in
the country – for example electrification, highways, communication, and port
installations – and monetary stability was also achieved (Torres Rivas 1993).
However, much agricultural land was appropriated for the cultivation of
cotton; at its peak it took up nearly 80% of the agricultural land in the fertile
Pacific region, particularly around León and Chinandega (Walker & Wade
2011; Staten 2010; Spalding 1994). The cotton boom thus led to further
concentration of land among the wealthy elite, at the same time as it required
a supply of a free, or cheap, labour force. As a consequence, many peasants
lost their land or access to land, and either started working as seasonal wagelabourers or moved to marginal, unfertile lands or into the cities to find
employment (Staten 2010; Pérez-Arias 1997; Hamilton & Chinchilla 1991).
Consequently, the urbanization rate rose during the 1940s, 50s and 60s (from
21% in 1940 to 39% in 196063) (Davis & Casis 1946; UN DESA Population
Division, Internet, accessed 2012-06-20). The geographical mobility of
migrant labourers, which had its origins already in the Spanish colonial era,
still continues as one of the most important migratory phenomena in the
region (Torres Rivas 1993). A number of Nicaraguans went into exile during
the long dictatorship, mostly to neighbouring Central American countries
(McKay & Wong 2000). Approximately 30,000 Nicaraguans emigrated
between 1950 and 70, according to UN statistics (UN DESA, Population
Division, Internet, accessed 2014-02-16).
Rapid industrialization and expansion of commercial export agriculture took
place during the 1960s and 70s, which led to economic growth and social
improvements (however, as described below, this growth did not benefit the
majority of the Nicaraguan population). More people moved into the cities, so
that by 1970 the urbanization rate had reached 47%64. The positive
development that took place is reflected in the HDI65, which began increasing
in the 1950s (from 0.381 in 1950 to 0.569 in 197566; Crafts 2002). The
observed changes in Nicaragua’s HDI between the 1950s and 70s reflect
improvements in economic, social and health conditions. For example, the
GDP per capita increased from US$231 in 1950 to over US$750 in 1976
(Weisskoff 1994; UNDP 1990). Enrolment rates in basic education also
improved (from 7% in 1950 to 86% in 1979), as did the literacy levels (from
63 Durand et al. (1965) give contrasting estimates, stating that the urban population equalled 15% of the total
population in 1950, and 23% in 1960. At that time, the urbanization rate in Nicaragua was ten percentage points
lower than that in other countries in Latin America (ibid.).
64 The urban population continued to grow over the coming decades, by 2-3% annually. In 1980 half (50%) of
the Nicaraguan population lived in cities, and in 1990 this figure was 52%. In 2010, the share had increased to
approximately 57% (UN DESA Population division, Internet, accessed 2012-06-20).
65 See Chapter 2 for further information on the Human Development Index (HDI).
66 The positive development did not sustain, however; in 1980, the HDI had dropped to 0.457 (UNDP, Human
Development Indicators, Internet, data accessed 2012-06-25).
92
38% in 1950 to 61% in 1979) (Newland 1994; Weisskoff 1994). Life expectancy
also increased during this period67 (from 42 years in 1950 to 55 years in 1975)
(Soares 2009; Acemoglu & Johnson 2006; UN DESA Population Division,
Internet, accessed 2012-06-20; UNDP 1990). The increased life expectancy
was related to positive declines in the infant mortality rate68 that also took
place during this period (from 140-180/1,000 live births in 1950-55 to 7090/1,000 live births in 1979) (Sandiford et al. 1991; UN DESA Population
Division, Internet, accessed 2012-06-20).
Somoza thus brought economic growth to Nicaragua, as well as improvements
in social and health indicators, but at the same time the socio-economic and
political inequalities grew. The improvements were disproportionately
concentrated to the privileged in society, due to the authoritarian rule and the
concentration of land (the Somozas owned about 20% of the country’s arable
land) (Walker & Wade 2011; Staten 2010). For example, in 1970 there was a
huge difference in average annual income between large estate owners
(US$18,226) and small-sized property owners (US$717), small plot
campesinos (US$445) and landless workers (US$370) (Torres Rivas 1993:
75). According to income distribution figures towards the end of the 1970s, the
wealthiest fifth of Nicaragua’s population earned about 60% of the national
income, while 80% had to settle for only 40%. The poorest half earned only
15% of the national income, which implied a yearly income of around US$200
per person (Walker & Wade 2011).
At the same time as the economy was growing the fiscal situation was
deteriorating, and by the end of the 1960s the burden of foreign debt was acute
in Nicaragua, just as it was in several other Central American countries. Then
in the 1970s the economic situation became even worse, due to the oil crisis
and decreases in export revenues. The gap between the richest and the poorest
consequently increased, and in 1979 the richest fifth of the country’s
67 Soares et al. (2009) conclude that the main reason behind this substantial increase in life expectancy was
overall improvements in people’s access to sanitation and treated water, more than economic growth per se.
Walker and Wade (2011) add that global medical advances, distributed via international organizations, were
central in the reduction of the death rate, particularly of infants and children.
68 In a study of infant mortality and fertility trends in León by Peña et al. (1999), results showed that the two
indicators declined simultaneously between 1964 and 1993. The decrease in infant mortality was primarily
related to health interventions, while the decrease in fertility was mainly explained by an increase in women’s
education (the share of educated young women more than doubled in the study period, from 20% to 46%).
Infant mortality declined most pronouncedly in the 1970s, when the average rate drop was 4.7 deaths per 1,000
live births for each year from 1974 and onward. The decline in infant mortality was equivalent to an annual
increase in life expectancy of 0.75 years each year over this period (Sandiford et al. 1991). Fertility rates declined
from 7.2 children per woman in 1950 to 6.3 in 1980 (this trend has continued over the years, and in 2010 the
figure was down to 2.7 children per woman). The Nicaraguan population subsequently grew during this period
(by about 3% annually during the 1950s, 60s and 70s, leading to doubled population numbers, up from
approximately 1.3 million in 1950 to 2.8 million in 1975 (UN DESA Population Division, Internet, accessed
2012-06-20).
93
population earned almost 20 times more (US$1,200) than the poorest fifth
(US$62) (Torres Rivas 1993: 121). Furthermore, Nicaraguan women endured
more disadvantages than the men, in terms of education, work opportunities,
and income. The eastern part of the country, and the indigenous inhabitants,
were also more socio-economically disadvantaged than the Pacific coast
(Walker & Wade 2011).
Opposition and armed uprisings against the Somoza dictatorship – which had
started already in the 1930s and 40s – became stronger in the 1960s (Walker
& Wade 2011). Influenced by Sandino’s struggle in the 1800s the Sandinistas
(Frente Sandinista de Liberación Nacional, FSLN) were formed in 1961,
dedicated to defeating Somoza. In the 1970s, they were joined in their struggle
by a Catholic grassroots organization. Years of agitation and armed conflict
against the Somoza regime ensued, in which many Nicaraguan women also
played an active role69. The dictatorship became harsher for every protest it
suppressed, but over time more and more supporters joined forces with the
opposition. The insecure situation caused thousands of Nicaraguans to
emigrate; either to Costa Rica, where approximately 20,000 Nicaraguans
resided in 1963, or to the US – primarily better-off Nicaraguans seeking
asylum (McKay & Wong 2000) – where about 10,000-16,000 Nicaraguans
lived in 1970 (IOM 2013; Morales & Castro 2006).
At the beginning of the 1970s the economic elite and other prominent citizens
also turned to the opposition, shortly after the devastating earthquake in
Managua in 197270 – which Somoza and his followers handled poorly – and
the killing of the oppositional journalist Chamorro (Walker & Wade 2009,
2011; Pérez-Arias 1997; Sangmpam 1995). American support to the Somoza
regime had also weakened by then because of changes in US politics (i.e. the
Carter Administration’s human rights policy). The US, together with other
critical countries as well as some of Somoza’s colleagues, tried to persuade
69 The foundation of women’s organisations in this period – such as AMPRONAC (Association of Women
Confronting the National Problem), which after liberation became AMNLAE (Luisa Amanda Espinosa
Association of Nicaraguan Women) – and their involvement in national politics led to some improvements in
women’s living conditions (Walker & Wade 2011).
70 In the 1972 earthquake, several thousand Managuans lost their lives (estimates range between 2,000 and
20,000), around 20,000 were injured, and 250,000 were left homeless. The economic losses were estimated at
between US$400 and US$600 million. The Somozan government made little effort to minimize the damages
immediately after the disaster (Kates et al. 1973) and reconstruction efforts were scant, at the same time as
Somoza and his associates lay claim to most of the international relief funds (Walker & Wade 2011). Nicaragua’s
geographical location and geological-geomorphological character, including its status as a developing country,
makes it particularly vulnerable to natural disasters, such as earthquakes as well as volcano eruptions and
hurricanes (Alcántara-Ayala 2002; Kates et al. 1973). The capital, Managua, has experienced severe shaking
and destruction on numerous occasions besides the largest one in 1972. Furthermore, a major eruption of the
volcano Momotombo in 1610 completely destroyed León, which was then rebuilt 20 miles away. The Cerro
Negro volcano has had more than 20 historically documented eruptions, most recently in 1999. Its largest
eruption took place in 1992 and caused several fatalities, as well as severe damage to land and property from
the lava flows and ash emissions (Freundt et al. 2006; Staten 2010).
94
Somoza at this point to step down from power (Pastor 1987). However, instead
of peacefully resigning, Somoza was defeated in 1979 by the Sandinistas
(Walker & Wade 2011).
The Somoza era was difficult for the countryside, we didn’t have roads, and it was
difficult to study… The “great” Somoza… I had to get involved against Somoza.
There were armed villages that fought Somoza, I had to go to the front…
(Fernando, 50 years, Cuatro Santos)
The costs of the war of liberation were high. The economic costs were
estimated at US$2 billion, and the country’s debt had moreover increased to
US$1.5 billion. GDP per capita dropped substantially, from US$999 in 1975 to
US$690 in 1980 (Staten 2010; UNDP 2000). The social costs were immense:
between 35,000 and 50,000 people had died (of whom 80% were civilians),
160,000 were wounded, and 40,000 children were orphaned. Moreover, a
third of all Nicaraguans (a million people) were in need of food, and another
250,000 of shelter, after the war (Staten 2010; Pastor 1987; Garfield, Frieden
and Vermund 1987). Of a total population of 3.1 million (UN DESA Population
Division, Internet, accessed 2012-09-28), it is estimated that between
100,000 and 200,000 men and women fled the country (mostly to Costa Rica
and Honduras) and that another 250,000-800,000 were internally displaced
(McKay & Wong 2000; Hamilton & Chinchilla 1991). Most refugees returned
to the country when the Sandinistas won the war (Hamilton & Chinchilla
1991).
The Sandinista years and the Contra war
Upon their victory, the Sandinistas declared that they had inherited from
Somoza “an extremely underdeveloped, disarticulated, and dependent
economy” (Robinson & Norsworthy 1985: 86). War damages totalled US$500
million, and the foreign debt amounted to US$1.6 billion (in terms of per
capita, the highest in Latin America) (Walker & Wade 2011). The conflictual
nature of Nicaraguan society at the time made it necessary for the Sandinistas
to make efforts to maintain national unity71. Despite the ambition of
unification, conflicts of interest led to increasing class polarization over the
years (Walker & Wade 2011; Pérez-Arias 1997; Robinson & Norsworthy 1985),
which partly explains the exodus of wealthy Nicaraguan citizens, who settled
71 Their political agenda was therefore based on four pillars: a mixed economy, political pluralism, ambitious
social programmes, and nonalignment (Walker & Wade 2011; Pérez-Arias 1997; Robinson & Norsworthy 1985).
According to Pérez-Arias (1997), four major issues dominated the political scene at this time, which the
Sandinistas tried to solve through their politics: the creation of a new, anti-colonial national identity; the
organization of agricultural reforms (i.e. nationalization of land); people’s representation in national
organisations; and the situation of the indigenous populations on the Atlantic Coast.
95
in neighbouring countries and the US (McKay & Wong 2000; Hamilton &
Chinchilla 1991). Nevertheless, the number of Nicaraguan emigrants was still
relatively low at that time (since many previous refugees had returned after
the revolution); in 1980, the migrant population was just under 3% (INIDE
2007b).
Despite the many problems and conflicts, the Sandinistas had secured a low
but steady economic growth by the beginning of the 1980s, partly thanks to
international loans and aid (Walker & Wade 2011). As promised in their
revolutionary programme, they nationalized a number of sectors within the
economy72, and thereby increased the public share of the country’s GDP from
15 to 41% (Pastor 1987). In order to curb unemployment in urban areas, the
Sandinistas established large-scale, infrastructural re-building projects
(Walker & Wade 2011; Staten 2010). Yet, the share of the population living
below the poverty line was still high in the period 1977-86, about 40% (UNDP
1990). To improve the lives of the impoverished rural population an agrarian
reform process was carried out, which by 1986 had transformed a quarter of
the private holdings into co-operatives and state farms, to the benefit of small
farmers and agricultural workers (seasonal, permanent and landless). The
workers’ wages and social conditions also significantly improved after the
reform, as did their access to land for subsistence farming. By 1983-84,
production of basic foodstuffs and export crops had surpassed the amounts
produced before the revolution, and the nutrition of the majority of the urban
poor, and of at least half of the rural poor, had improved (Barraclough & Scott
1987). Most importantly, the Sandinistas managed to carry out far-reaching
social programmes, which improved the health and welfare services for a
majority of the poor Nicaraguan population. During the first four years of
Sandinista rule the country’s health care system underwent a complete
change, as reflected in the government spending on health care, which
increased sixfold compared to the spending two decades earlier73 (UNDP
1990). Health care services that had been damaged or destroyed in the war
were rebuilt, and new services were added to expand the provision of health
care in both rural and urban areas (for example, the number of communitybased primary care centres more than doubled74) (Braveman & Siegel 1987).
By 1985, the majority of the Nicaraguan population (88%) had access to health
services. Furthermore, half of the population (49%) had access to safe water,
72 For example, banking industries, trade of agricultural products, mineral companies, and Somoza’s
properties.
73 From 0.4% of GNP in 1960 to 6.6% in 1986. A 50% increase took place between 1977 and 1981 (Braveman &
Siegel 1987), and a 200% increase between 1978 and 1983 (Walker & Wade 2011; Staten 2010). From 1980 to
1990, the increase was from 3.2% to 4.9% (UNDP 1996).
74 From 172 in 1977 to 487 in 1984.
96
and 27% had access to sanitation75 (UNDP 1990; UN DESA Population
Division, Internet, accessed 2012-09-28). Vast and successful vaccination
campaigns were also carried out by volunteers, with the ambition to prevent
diseases such as polio, infant diarrhoea, leprosy and malaria. The decrease in
infant mortality, which, as mentioned, had already begun decreasing by the
beginning of the 1970s, continued with increasing force thanks to these
efforts. By 1988 the infant mortality rate was down to 61 deaths/1,000 live
births76, and life expectancy had also increased77 (UN DESA Population
Division, Internet, accessed 2012-06-20; UNDP 1990). Additionally, the
Sandinistas increased the spending on education sixfold compared to the
spending in 196078. One important action was their establishment of a
national literacy programme, which improved the literacy level so that by
1988, 88% of the population could read and write (Walker & Wade 2011;
Staten 2010; Pastor 1987; UNDP 1990).
After the introduction of political freedom in 1984, the Sandinistas – headed
by former FSLN leader Daniel Ortega – won the first democratic election in
Nicaragua’s history with 63% of the votes79 (Walker & Wade 2011). The leftist
convictions of most Sandinistas nevertheless aroused suspicion, as well as
opposition, amongst the elite in Nicaragua and abroad; even though their rule
was rather pragmatic and moderate. The US, who had been relatively neutral
towards the Sandinistas under Carter, became – after the election of Ronald
Reagan in 1980 – increasingly wary of the “communist” threat (Pastor 1987).
Economic sanctions80 were imposed, and military support was later given to
former National Guardsmen and other oppositionals stationed in
neighbouring Honduras, with the ambition to overthrow the Sandinistas. The
Contra war that followed came to last for several years, with high socioeconomic costs for the country. About 250,000 people were displaced from
their homes (Garfield, Frieden & Vermund 1987), and many also fled the
country; between 1985 and 1990, 156,000 Nicaraguans emigrated (UN DESA,
Population Division, Internet, accessed 2014-02-16). In 1989 somewhere
between 22,000 and 100,000 Nicaraguans lived in Costa Rica (Hamilton &
Chinchilla 1991), of whom 34,000 were officially registered as refugees
(Larson 1993). According to IOM (2013), around 100,000 Nicaraguans were
75 There were, however, vast differences between urban and rural areas. In the rural population (which in 1988
made up about 50% of Nicaragua’s total population of 3.7 million), only 60% had access to health services, 11%
to safe water, and 16% to sanitation.
76 This positive trend has continued, and by 2010 the infant mortality rate was down to 21 deaths/1,000 live
births.
77 Life expectancy was 64 years in 1987; by 2011 it was almost 20 years longer, i.e. 74 years.
78 From 1.5% of the GNP in 1960 to 6.1% in 1986.
79 Internationally, the election was considered free and just; however, the US unsuccessfully tried to control,
undermine and discredit it.
80 For example, the termination of aid and decreases in sugar quotas.
97
officially registered in Costa Rica by then, and several more thousands were
believed to be in the country illegally (Larson 1993). In the US, 10,000
Nicaraguans were granted asylum between 1983 and 1992 (Orozco 2008,
referred to by IOM 2013). By 1985 a total of 50,000 Nicaraguans lived in the
US (McKay & Wong 2000), and by 1990 almost 170,000 Nicaraguans were
officially registered there (Morales & Castro 2006)81. US-Nicaraguan
communities had begun to develop by then, especially in Miami and Los
Angeles (McKay & Wong 2000).
The Contra war was terrible, whole villages died…
(Fernando, 50 years, Cuatro Santos)
When the war ended the death toll was estimated at over 30,00082, and
another 20,000 had been wounded (Walker & Wade 2011; Staten 2010). The
war also had high psychological costs, with increased rates of depression and
anxiety amongst the population (Braveman & Siegel 1987). Moreover, social
service institutions (e.g. schools and health care facilities) had suffered great
damage and destruction, as well as the death of many professionals83 (Walker
& Wade 2011; Braveman & Siegel 1987; Garfield, Frieden & Vermund 1987).
Furthermore, the health services that still existed were strained by the high
number of war injuries and often lacked the necessary equipment and
medicines. In 1988 the total war damages amounted to US$12 billion. About
half of the national budget had been consumed to cover the high war
expenditures, leading to cuts in economic and social programmes, which
worsened the socio-economic situation even more (Walker & Wade 2011;
Staten 2010; Pastor 1987). Nevertheless, the country’s HDI continued rising,
and by 1985 was 0.660 (UNDP 1991).
At the same time as Nicaragua was struggling with the civil war, the country’s
economy was hit by the global recession that followed the oil crisis of the
1970s84. Between 1980 and 1987, the GNP per capita had a growth rate of
81 The Pew Hispanic Center (Brown & Patten 2013) estimated that 141,000 Nicaraguans in the US had entered
the country before 1990 (of a total of 395,000 Nicaraguans residing in the US in 2011).
82 22,000 Contra soldiers, 4,000 government troops and 4,000 civilians.
83 The targeting of social service institutions was a warfare strategy of the Contras. More than 130 teachers, 40
doctors and nurses, and 190 technicians and other professionals were estimated to have died in the war.
84 All Central American countries were negatively affected by the world recession of the 1980s; GDP per capita
fell by an average of 18% during the decade (Zuvekas 2000). The negative economic growth was mainly due to
three factors: external causes (i.e. rising oil prices and declining export prices), internal structures (e.g. debt
problems, fiscal deficits, capital flight), and political instability or armed conflicts. Nicaragua was the hardest
hit; to a great extent due to the Somoza “inheritance” and the costly warfare against the Contras. While the
economies of the rest of Central America recovered after 1986, the decline continued in Nicaragua (Torres Rivas
98
-4.7% annually (UNDP 1990); and in 1985 the per capita income was down to
US$611 (UNDP 2000), which equalled that of 1965 (Torres Rivas 1993).
Nicaragua’s foreign debt also increased heavily during the first years of the
1980s, like most countries on the isthmus85. The debt situation was most acute
in Nicaragua, however, which stood for 35% of the region’s summed debt in
1990 (about US$8 billion) (Zuvekas 2000). By the end of the 1980s, the
economic situation had become unsustainable. GDP per capita decreased by
20% in just a year (between 1988 and 198986), and inflation rose dramatically
– to 33,000% at its peak – after an attempt to increase relative prices through
devaluation. To ease the situation the Sandinistas undertook economic
reforms, predominantly wage cuts and reductions in public expenditures
(Walker & Wade 2011; Staten 2010). As a consequence, unemployment rose
by 8% in five years’ time87 (LABORSTA, Internet, data accessed 2012-06-29).
The country’s HDI decreased to 0.496 in 1990 (UNDP 1992), and the great
differences between the poor and rich in society continued. For example,
during the years 1980-1994, the richest 20% had incomes 13 times higher than
those of the poorest 20% (UNDP 1997).
Due to the economic collapse, harsh living conditions, the exhausting Contra
war, and increasing political instability, in the 1990 election the war-weary
Nicaraguans voted in favour of Conservative presidential candidate Violeta
Barrios de Chamorro (Walker & Wade 2011; Torres Rivas 1993). Edelberto
Torres Rivas (1993) sums up the chaotic 1980s as follows:
Social justice has not produced the economic surplus essential for the invigoration of
an economy progressively in crisis by 1982 and unmanageable by 1988, when a series
of unpopular economic adjustments were instituted. Social change has regressed, the
market has become informal, contraband and inflation, uncontrollable. Since 1989,
the Nicaraguan economy has totally collapsed. Under these conditions, the February
1990 elections took place and the opposition won. (Torres Rivas 1993: 129)
The Conservative era and the return of Daniel Ortega
Two decades of conservative rule followed, characterized by neo-liberal
economic policies (e.g. structural adjustment programmes) as well as
corruption scandals. Walker and Wade (2011) also argue that the social
improvements that had been made for the poor population, for example in
health care, were greatly undermined during the conservative governments.
1993). To alleviate poverty, in 1987 the country received US$141 million in official development assistance
(ODA), but this only made up 4.4% of the GNP (UNDP 1990).
85 Between 1980 and 1983 the external debt of Central America doubled from US$7.7 billion to US$14.2 billion,
and by 1990 the total debt amounted to US$23 billion.
86 GNP per capita in 1989 was US$830 (UNDP 1992).
87 From 3% in 1985 to 11% in 1990.
99
During the Chamorro government (1990-1997) economic liberalizations
accelerated, inflation was successfully curbed, and a slight economic growth
took place. Yet the external debt still increased, reaching US$11 billion (one of
the highest in the world) by 1992 (Staten 2010; Walker & Wade 2011). By 1995
the debt was down to US$10 billion, but still made up 670% of the GNP
(UNDP 1999). In return for foreign aid and loans, agreements for structural
adjustments to the economy were made with the International Monetary Fund
(IMF) and the World Bank, which led to substantial budget cuts, the
privatization of state-run businesses, support to large-scale agro-export
(which made it difficult for small- and medium-scale peasants), and the
expansion of free-trade zones for assembly shops (maquiladoras) (Staten
2010; Mendez 2005). The first state-owned maquiladora opened in 1992 and
by late 2001 there were 44 assembly factories in operation, the majority of
which produced garments for the US market (Observador Económico 2002:
5; referred to by Mendez 2005). The number of workers employed in the
maquiladoras grew rapidly – from around 1,000 in 1992 to approximately
7,000 in 1995 (and to nearly 40,000 in 2002) – as did the factories’ export
production (from US$2.9 million in 1992 to US$250 million in 2001,
equalling 30% of all export from the country at the time) (Mendez 2005;
Robinson 2001).
The vast majority of the Nicaraguan population suffered greatly because of the
structural adjustments. The decrease in the GDP per capita continued88, and
hit its lowest value in 1993 – US$419 (UNDP 2000). Unemployment rose
dramatically, and by 1996 half of the population was either unemployed or
underemployed (Staten 2010). The cuts in public spending had dramatic
effects on the social sectors; the government’s expenditure on health
decreased substantially, as naturally did people’s access to health services89
(UNDP 1990, 2000). People’s access to education also decreased, and the
literacy levels – which had improved dramatically during the revolutionary
years – went down by 25 percentage points (to 63% in 1997) (UNDP 1998,
1999). Staten (2010) argues that since these measures were taken, health care
as well as education of quality could only be afforded by the richer segments
of society. Furthermore, diseases that had previously almost been eliminated
began reappearing (for example, cholera, dengue fever and malaria) (Staten
2010). The worsened socio-economic situation the country experienced in this
88 The GDP per capita decreased steadily from the middle of the 1970s. A large decrease took place between
1985 and 1990 (from US$611 to 460), and the decrease continued during the 1990s (from US$460 in 1990 to
US$452 in 1998) (UNDP 2000).
89 The expenditure on health went from over 6% in 1986 to 1% in 1990. The share of the population – which in
1995 amounted to around 4.6 million (UN DESA Population Division, Internet, accessed 2012-09-28) – with
access to health services generally decreased during the period, from 88% in 1985 to 83% 1990-95.
100
period is mirrored in Nicaragua’s decreased ranking in the HDI90 (UNDP
1998, 1999). The unemployment rate peaked in 1993, at almost 18% (IOM
2013, with reference to FUNIDES 2007). During the years 1989-1994, half of
the population lived in poverty (below the national poverty line), and 44%
were extremely poor (living on less than US$1 a day) (UNDP 1997). As a
consequence of the deteriorating living conditions, more and more
Nicaraguans looked for better opportunities abroad. Between 1990 and 1995
approximately 70,000 emigrated to Costa Rica, and about 30,000 to the US
(IOM 2013).
During the Chamorro years the armed conflict between the former Contras
and Sandinistas continued, albeit sporadically, despite the peace agreements
of 1990. Chamorro made efforts for national reconciliation; however, since
this policy was not appreciated by everyone in her party, some members
formed a new party – the Liberal Alliance (PLC) – with support from the US.
The leader of the PLC, Arnoldo Alemán, subsequently won the 1996 election
(Staten 2010; Walker & Wade 2011).
The Alemán years (1997-2002) were marked by polarization, administrative
incompetence – especially in the aftermath of the devastating Hurricane
Mitch91 in 1998 – and the vast corruption of Alemán and others in the
administration (Walker & Wade 2011; Staten 2010). The country’s debt
problem grew out of proportion – in 1998, the external debt amounted to
almost US$6 billion, equalling 336% of the GNP (UNDP 2000) – which led to
an acceleration of the IMF- and World Bank-induced structural adjustments
to the economy. The macro-economic situation slightly improved, and
expenditures on, for instance, health increased somewhat (from 1% in 1990 to
4% in 1996-98) (UNDP 2000). However, in relation to cuts in government
spending, the social sectors received less funding, which led to higher levels of
unemployment92 and lower wages; overall, to a deterioration of living
conditions for a majority of the population (Staten 2010). Poverty was
90 From 71st place in 1990 to 127th in 1997. However, as shown in the Human Development Report 1999 (UNDP
1999: 166), the changes in HDI values over time are explained to some extent by changes in the methodology
used. For Nicaragua, three of four changes in ranking between 1998 and 1999 are explained by the refined
methods used in 1999.
91 Hurricane Mitch – one of the most powerful Atlantic hurricanes ever witnessed – struck Central America in
1998 with far-ranging socio-economic and environmental consequences. The number of primary victims in
Nicaragua was high (around 3,000 dead, 300 wounded and 1,000 missing, half of whom were children), and
the number of displaced/homeless people was around 860,000 at its highest. The summed cost of all damages
was around US$988 million, which equalled 45% of the country’s GDP. (The productive sectors – e.g.
agriculture, industry and tourism – stood for 37% of the total damages, followed by infrastructure – especially
transport and communication – at 34%, and the social sector – particularly housing – at 27%). Besides the costs
of damages, another US$1.3 billion was needed for reconstruction. The departments of León and Chinandega
suffered the highest losses and costs (UN/ECLAC 1999).
92 Just during the first years of Alemán’s presidency, about 12,000 government employees lost their jobs. In
1998, the official unemployment figure was 13% (IOM 2013, with reference to FUNIDES 2007).
101
widespread (UNDP 2003), and the differences between the richer and the
poorer of society were great (for instance, the Gini coefficient was 0.60 for the
period 1990-98; UNDP 2001)93. The number of Nicaraguans who emigrated
to Costa Rica and the US increased by tens of thousands, and by the end of the
decade totalled almost 500,000 (half in each country) (IOM 2013). Civil
unrest accompanied the economic crisis94, and Alemán subsequently lost
power to his Vice-President, Enrique Bolaños, in the 2001 elections (Walker
& Wade 2011; Staten 2010).
At the beginning of Bolaños’ presidential term (which lasted from 2002 to
2007), the Nicaraguan economy was completely run-down and social
problems were extensive (Walker & Wade 2011). Poverty was still widespread,
though the share of the population suffering from extreme poverty had
decreased somewhat (during the period 1990-2003 80% of the population
was poor, living on less than US$2/day, and 45% suffered from extreme
poverty, living on less than US$1/day) (UNDP 2005). The debt burden was
acute, and the country was consequently admitted to the Highly Indebted Poor
Countries Initiative (HIPC)95, which led to the cancellation of much of its
foreign debt (IMF 2004; Walker & Wade 2011). In 2005, Nicaragua entered
the Central American Free Trade Agreement (CAFTA), which generated slight
economic growth96. However, the socio-economic situation for the
Nicaraguan population at large did not improve to any greater extent during
Bolaños’ presidency97 (Walker & Wade 2011). Emigration continued due to
the harsh living conditions; about 50,000 more Nicaraguans moved to Costa
Rica, and approximately 25,000 to the US. Some new migration trends also
emerged during the period: increasing intra-regional migration to primarily
El Salvador and Panama, but also emigration to Spain (IOM 2013).
During his presidency, Bolaños took great measures against corruption, which
led amongst other things to the conviction of former President, Alemán, for
the embezzlement of over US$100 million in public funds. Nevertheless,
93 Furthermore, during the years 1987-1998 the share of income of the richest 20% was 55%, or 13 times that
of the poorest 20% (UNDP 2000).
94 The political alliance between Alemán and Daniel Ortega – el Pacto – was initiated during this period to still
the civil unrest; a collaboration that continued, as mentioned later in the text.
95 HIPC was launched by the IMF and the WB in 1996 with the aim of reducing or canceling heavily indebted
countries’ external debt. Countries go through different steps in the process (see IMF Factsheet, available at:
http://www.imf.org/external/np/exr/facts/pdf/hipc.pdf); Nicaragua reached the decision point for HIPC
entry in 2000, and the completion point in 2002. The estimated debt relief to the country amounted to US$3.3
billion – the largest amount approved up to that time – which was thought to reduce Nicaragua’s external debt
by 72% (see IMF 2004 for further details about Nicaragua’s progress under HIPC).
96According to Walker and Wade (2011), the economic growth was greatly related to luxury consumption by
the elite, as well as agricultural exports, which grew somewhat after entrance into CAFTA.
97 In 2003 the HDI was 0.690 (112th place) (UNDP 2005), and in 2007 0.699 (UNDP 2009). The annual growth
rate of HDI for 2000-07 was 0.7% (ibid.). During the period 2000-2007 48% of the population was poor, with
32% living on less than US$2 a day (poor) and 16% on less than US$1.25 a day (extremely poor) (ibid.).
102
Bolaños’ crusade against corruption was not appreciated in the political
sphere at large, and he consequently worked in opposition during the
remaining years of his presidential term98. The conservatives were a split
faction at this point – for example, a large faction of PLC had formed into a
new party (ALN) – which put the FSLN and Daniel Ortega in a more
advantageous position. In 2006, Daniel Ortega won the presidential elections
with 38% of the votes99 (Walker & Wade 2011; Staten 2010) and the
Sandinistas thus regained power 27 years after the revolution. Their reinauguration spread high hopes for a better future for the country, especially
for its poor population (Walker & Wade 2011; Staten 2010).
We’re waiting for the new government to maybe do something… I
mean, it’s difficult, because the country is so… well, only international
solidarity [aid] can help countries that are in crisis.
(Fernando, 50 years, Cuatro Santos)
Living conditions during the fieldwork period
This section focuses on the socio-economic and political situation in
Nicaragua during the period in which this study takes place100. Besides issues
such as politics, the labour market, incomes, poverty levels, and education, the
section also discusses health issues and contemporary migration patterns.
The Ortega administration
Daniel Ortega’s message in the 2006 election campaign of “reconciliation
between the rich and poor, the state and the Church, and the political left and
right” (Staten 2010: 151) appealed strongly to the majority of the Nicaraguan
population. He seemed to provide solutions to the widespread poverty and
social problems, and to the ongoing energy crisis101. Due to the strained
economy, however, the social actions promised during the election campaign
98 In 2004, Bolaños left the PLC to start a new party. Political allies Alemán (PLC) and Ortega (FSLN) did not
settle for this, however, but rather worked together to block the way for Bolaños, for instance by pushing
through constitutional reforms that limited presidential authority, and by blocking laws that Bolaños had
suggested (e.g. laws necessary for the disbursement of IMF loans).
99 Due to changes in electoral laws passed some time before the election, a majority of the votes was no longer
necessary to win the presidency. Another important reason behind Ortega’s success was, furthermore, the
support he received from the Catholic Church as a result of his controversial decision to support the prohibition
of therapeutic abortion.
100 It was just around the re-election of FSNL and Daniel Ortega that the fieldwork for this study took place.
This naturally influenced the spirit of the time, and the people who participated in the study, which is something
that should be taken into account.
101 For which Ortega turned to Venezuela’s Hugo Chavez for help.
103
were difficult to carry out as extensively as planned; yet some vital
programmes were nevertheless introduced, such as Zero Hunger, Houses for
People, and the literacy campaign Yo Sí Puedo (Staten 2010). The optimism
felt by many Nicaraguans when the FSLN regained power faded somewhat
over the years, partly because of Ortega’s “corruption of the rule of law”
(Walker and Wade 2011: 78). The government’s control over the judiciary (i.e.
the Supreme Electoral Council) increased steadily, which led to political
advantages for Ortega (for example, by keeping other political leaders –
including Ortega’s collaborator Alemán – under control because of fears of
corruption charges). Furthermore, in 2009, the constitutional prohibition
against presidential re-elections was removed by the FSLN-controlled
justices. Ortega could thus run for President again, and was re-elected in 2011.
During recent years, opposition has grown against Ortega’s increasingly
“authoritarian” rule, and several incidents of intimidation and harassment
have been reported by oppositionals (Walker and Wade 2011).
The political climate in Nicaragua after the re-election of the FSNL and Ortega
has had repercussions on the country’s relations with other nation-states. For
instance, in August 2007 Sweden put an end to 30 years of development cooperation102. Although the official reason behind this decision was the new
direction in Sweden’s policies for global development – particularly the focus
on fewer countries (“landfokuseringen”)103 – critical voices have argued that
it was also related to what the new Conservative (right-wing) Swedish
government regarded as a “leftist” turn in Nicaraguan politics (see e.g. leftwing politician Hans Linde in Arvidsen/Fria.nu, 20/08/07). It was also
suggested to be connected to human rights violations; for instance, the
questioned independence of the judiciary and the legislation against
therapeutic abortion (Öström & Lewin 2009)104. Sweden’s (and other
countries’) discontinuation of development aid to Nicaragua influenced
Nicaraguan authorities to look for new collaborations. Venezuela, for
example, has risen in importance.
The socio-economic situation
As shown in the first half of this chapter, the Nicaraguan economy has long
been under pressure. Even at the beginning of the 21st century – when this
study was undertaken – the country faced difficult times. In 2008, in a World
Bank report, Gutierrez and colleagues (2008) seemingly characterized
102 See Öström (2009) for an overview of the Swedish development aid to Nicaragua.
103 See Regeringskansliet (March 17 2008); and Regeringskansliet/Utrikesdepartementet (August 27 2008).
104 Caution is also voiced regarding these issues by the Swedish Embassy in Nicaragua in their 2007 Country
Report on Nicaragua (Sida 2008).
104
Nicaragua as a “typical low-income country”, with widespread poverty, large
agricultural and informal sectors, low educational level, little formal
employment, low income levels and a high level of child labour. These issues
will be discussed in this section, and towards the end attention is turned to the
health care system and health situation.
During the fieldwork period, Nicaragua’s GDP per capita was on average
US$1,470 (UNdata, Internet, accessed 2014-02-13)105. The country’s external
debt was US$3.8 million at its lowest (in 2007) and US$7 million at its highest
(in 2011). The total debt service (as percentage of exports of goods, services
and income) ranged between 10% (2006) and 18% (2009)106. Nevertheless,
the country did experience economic growth during the period (+4.5%),
except for the year 2008 (when the growth was -2.2%). Foreign direct
investments positively increased over the period; from US$287 million in
2006 to US$810 million in 2012, equalling about 13% of the GDP. The country
also received approximately US$735 million (annual average) in development
assistance/aid (ODA) (in 2010, ODA equalled 10% of the GNI). The value of
exports of goods and services increased over the period, from 27% of GDP to
almost 40%. In 2010, almost 80% of the exports consisted of agricultural
products, which was high compared to other countries. Only 6% of the
country’s exports consisted of manufactured products. Nevertheless, the share
of industry in the GDP was higher than that of agriculture – 23% compared to
18%.
In Nicaragua eight of ten men are active in the labour force, while only about
half (47%) of the women are employed outside the home (CEPAL 2011). The
official unemployment rate in Nicaragua has been below 10% for many
decades; in 2010, for example, it was 7.5%. Youth unemployment was 10%
(2005-2011). Yet, at the same time, more than 50% of the population – which
amounted to six million in 2012 – claims to suffer from underemployment
(hence not working full-time or as much as desired). The majority (76%)
works in the informal sector107. Moreover, child labour is common in the
country – it is estimated that 15% of all children work (2001-2010) (UNDP
2013). According to the most recent labour force survey, conducted in 2006,
the sector that employed the most Nicaraguans was agriculture, hunting and
forestry (28%). The second largest sector was wholesale and trade, as well as
105 Average for the years 2006-2012. This is low in comparison with other countries in Latin America, and with
the world as a whole (see UNDP 2013). The GDP (in US$) increased during the period - from US$6.7 billion (in
2006) to US$10 billion (in 2012) (UNdata, Internet, accessed 2014-02-13).
106 Measured as percentage of GDP, the debt service made up 8% in 2009, which is high compared to other
countries and regions of the world (see UNDP 2013).
107 Another indication of the low degree of labour market formalization is that only 19% of the labour force has
access to social security (Gutierrez et al. 2008) (those who are self-employed are not eligible for social security
unless they pay for private insurance).
105
repairs (20%), and the third largest was manufacturing (14%). Men were more
often employed in the first sector (e.g. agriculture), while women more
commonly worked in the second (e.g. sale)108 (UNdata, Internet, accessed
2014-02-13). Due to the lack of formal employment, people create their own
jobs – in agriculture, commerce, service, and other sectors. Pozzoli and
Ranzani (2009) therefore argue that the main labour market issue in
Nicaragua concerns how to get people good jobs with decent pay, rather than
simply getting people to work.
In 2009 the annual income of Nicaraguans was C$13,700109 on average.
However, the average income varies greatly between the country’s richest and
poorest. For example, urban households earn about C$16-17,000, whereas
rural households only make C$8-9,000. The non-poor, who mainly get their
income from non-agricultural sectors, had an average annual income in 2009
of C$28,000, whereas the poor and the extremely poor only earned C$9,600
and C$6,800, respectively (INIDE 2011)110. Due to low incomes, for many
Nicaraguans it is difficult to make ends meet. In 2006, for example, seven of
ten Nicaraguans could not afford to buy what they needed to live on (Walker
& Wade 2011, with reference to CENIDH 2007 “Derechos Humanos en
Nicaragua 2006”). Consumer prices increased substantially between 2006
and 2008111 (UNdata, Internet, accessed 2014-02-13), which indicates that
living costs became more expensive during this period.
The country received increasing amounts of remittances during the period this
study took place – from US$698 million in 2006 to over US$913 million in
2011; thus, more than both foreign direct investments and foreign aid, and
about 10% of the country’s GDP (UNdata, Internet, accessed 2014-02-13)
(12.5% of GDP in 2010, according to UNDP 2013). Remittances are mostly
sent from North America (66%) and Latin America (33%) (just 2% are sent
from Europe) (UNDP 2009). The money sent home is used mostly for
consumption (e.g. food, clothes)112, health care and education (Morales &
Castro 2002). According to Jennings and Clarke (2005), about 5-10% of
108 Moreover, the second sector was the second most common employer for men, whereas the third sector (e.g.
manufacturing) was the second most common employer for women. Eight per cent of women worked in
agriculture, and 12% of men in manufacturing (UNdata, Internet, accessed 2014-02-13).
109 In 2014, 1,000 Nicaraguan córdobas equalled 38 US dollars. An average annual income of C$13,700 thus
corresponds to US$527.
110 In 2005, the income share held by the 20% with the lowest income was 6% (2% higher than in 1993)
(UNdata, Internet, accessed 2014-02-13). The income Gini coefficient for the years 2000-2010 was 0.40 (UNDP
2013).
111 The consumer price index almost doubled from 2006 to 2008 – from 161 to 214 (1999=100). The food index
increased slightly more.
112 According to CEPAL (1999) (referred in Jennings & Clarke 2005), 75% of remittances are spent on consumer
items.
106
remittances are also used for savings and investments in, for example,
agriculture and family businesses.
As the latest Human Development Report (UNDP 2013) shows, Nicaragua’s
HDI has – slowly but surely – continued to increase over the years. Still, the
country’s HDI ranking has not changed much (in fact, not at all during the
fieldwork period, 2007-2012); with the result that the country still remains at
“medium” human development113. Nicaragua lags behind the Latin American
average of HDI. Moreover, when the HDI is adjusted for different inequalities,
substantial decreases in HDI take place114. For example, when taking into
account the distribution of the HDI across the population, as measured in the
Inequality-adjusted HDI (IHDI), about 28% of the HDI value is lost.
Additionally, the UNDP’s poverty index shows that almost 13% of the
population suffers multiple deprivations115. One example of what these
numbers reflect is the poverty from which many Nicaraguans suffer in their
everyday lives. In 2005, the share below the national poverty line (set at living
expenses less than US$2/day per person) was 48% (UNdata, Internet,
accessed 2014-02-13)116. The share living on less than US$1.25 per day was
12%. Furthermore, in 2009 it was estimated that 28% of the population lived
in multidimensional poverty (UNDP 2013). The proportion of Nicaraguans
living in extreme poverty has certainly decreased since the 1990s, from 32%117
in 1993 to 11% in 2006 (INIDE, 2011); however, the share under the national
poverty line (below US$2/day) has not decreased as dramatically, if at all.
Furthermore, almost a quarter of the population (22%) was undernourished
in 2012, despite the slow decrease that has taken place (UNdata, Internet,
accessed 2014-02-13). Poverty is spread unevenly in different parts of the
country, and among different social groups. It is generally more widespread
in the rural areas of Nicaragua, where 67% of the population is poor, in
contrast to 29% in urban areas (average 2005, 2009) (UNdata, Internet,
accessed 2014-02-13; INIDE, 2011). Additionally, the Caribbean Coast is
generally more socio-economically disadvantaged than other areas of the
113 Nicaragua’s HDI value over the past decades: 0.461 in 1980; 0.479 in 1990; 0.529 in 2000; 0.572 in 2005;
0.583 in 2007; 0.593 in 2010; 0.599 in 2012. Change in HDI ranking 2007-2012: 0 (UNDP 2013).
114 Since 2010 the HDI has been supplemented with three more indices – the Inequality-adjusted HDI (IHDI),
the Gender Inequality Index (GII), and the Multidimensional Poverty Index (MPI) – which account respectively
for inequalities in HDI across the population, gender-based disadvantages and multiple deprivations. MPI is
expressed as a percentage, whereby 100% is the maximum deprivation score. IHDI and GII are expressed in
the same way as HDI, as a value between 0 and 1, and if inequalities exist in the country there will be a loss in
HDI value. The IHDI for Nicaragua was in 2012 0.434, indicating a loss of 27.5% of HDI. For the same year, the
GII was 0.461 (thus, a loss of HDI of 0.138 points, or 23%). See Technical notes 2, 3 and 4 in
http://hdr.undp.org/sites/default/files/hdr_2013_en_technotes.pdf, for further details on the indices.
115 The MPI for 2006-2007 was 0.128, which means that 12.8% of the population lived in multidimensional
poverty.
116 In 2009, 43% of the population lived below the national poverty line.
117 In contrast to INIDE (2011), data from the World Bank in the Millennium Development Goals Database
estimate the share of extremely poor in 1993 to 18% (UNdata, Internet, accessed 2014-02-13).
107
country; and the indigenous populations, in particular, suffer more from
poverty than other ethnic groups (INIDE, 2011). Wilton Pérez (2012) states
that there has indeed been progress toward meeting some of the Millennium
Development Goals (MDGs), especially regarding the levels of extreme
poverty, which in 2005 had decreased to 12% (from 18-32% in 1993,
depending on the source; see Footnote 117). Nevertheless, it is estimated that
Nicaragua will not achieve all of the MDGs by 2015. Pérez particularly points
out that great social inequalities exist, for example the fact that poverty is
more than twice as great in rural than in urban areas, and higher in the
Caribbean region than the Pacific region.
About 4-5% of the GDP was spent on education during the period 2000-2010.
For the period 2005-2010, the majority (78%) of the population aged 15 years
or over was literate. In 2010, the mean number of years of schooling was 5.8,
and the expected years of schooling (in 2011) was 10.8. Of the population aged
25 years or more, 38% had at least a secondary education in 2010. The primary
school dropout rate was 52% (2002-2011), which is high in comparison with
the world on average, and with other countries with a “medium” HDI (UNDP
2013; UNESCO, Internet, accessed 2014-02-13).
Health indicators and health care
Improvements in health indicators have positively continued, even in recent
decades. For example, in 2012 life expectancy at birth was 74.3 years and the
fertility rate was 2.5 (down from 3.3 in the year 2000) (nevertheless, the
population is still very young; in 2010, the median age was 22.1 years). The
maternal mortality rate in 2010 was 95/100,000 live births118. For the same
year, the infant mortality rate was 23/1,000 live births, and the under-five
mortality rate was 27/1,000. The immunization coverage (for measles, etc.) in
2010 was 99%. The suicide rate was 6/100,000 (the male suicide rate was
higher, at 9, than the female rate of 2.6) (UNDP 2013). Nevertheless,
Nicaragua will have difficulty reaching the health-related targets of the MDGs,
especially those concerning maternal and child mortality, even though slow
progress is taking place (Angel-Urdinola, Cortez & Tanabe 2008). Pérez
(2012) shows that the reduction in child mortality was substantial between
1990 and 2011 (from 64 to 29 deaths per 1,000 live births; hence a reduction
of 55%) but that the pace of this change has slowed in recent years, and also
that great social inequalities exist, which makes it impossible to foresee
whether the MDG4 will be reached in 2015 (see Pérez 2012, for the progress
of the MDGs in León and Cuatro Santos; also discussed later in the chapter).
Furthermore, a serious public health problem in the country is the widespread
118 Down from the 2008 level of 100/100,000 live births (UNDP 2011).
108
violence against women. A groundbreaking study, conducted by Mary Carroll
Ellsberg (2000) in León in 1995, showed that over 50% of married women had
been exposed to physical violence at some point in life, and that a fifth (21%)
had suffered from not only physical and sexual but also emotional abuse. A
decade later, Eliette Valladares Cardoza (2005) showed that 13% of pregnant
women reported having been physically abused during pregnancy (in 2004).
In 2006/2007 the prevalence of physical, sexual, and emotional abuse (i.e. the
proportion of the population who had been abused in the past year) was 21%,
8%, and 6%, respectively119 (INIDE 2008) (however, there is probably vast
underreporting on these matters). In a study on adolescent pregnancies,
Elmer Zelaya Blandón (1999) furthermore showed that at age 17, one-fourth
of girls had had their first pregnancy; and that 16% of all girls, and 28% of
pregnant girls, had experienced sexual abuse (in 1996). Early pregnancy thus
seemed to be associated with the sexual abuse of children and teenagers.
Although achievements have been made in some health indicators and the
right to equal access to health care is postulated in Nicaraguan law – and the
government’s expenditure on health is at a “reasonable” level, about 4-5% of
the GDP (which is similar to, or higher than, in neighbouring countries at the
same level of “development”; UNDP 2013) – there are substantial socioeconomic and geographical inequities in health, and in people’s access to
health care (Angel-Urdinola, Cortez & Tanabe 2008; Sequeira et al. 2011).
These inequities can be explained by how the health system is built. The
Nicaraguan Ministry of Health (MINSA) is responsible for assuring that the
population has access to health care, and does so by administering the health
system in three sectors: the non-contributory, the contributory, and the
voluntary (Muiser, del Rocío Sáenz & Bermúdez 2011). Like in many other
countries, the provision of health care is structured in three levels: the
primary, secondary, and tertiary sectors120. MINSA is responsible for the
services in the non-contributory sector, the beneficiaries of which are mostly
those who cannot afford to pay for other health services, and those who lack
119 A study by WHO (García-Moreno et al. 2006) including ten countries (Bangladesh, Brazil, Ethiopia, Japan,
Namibia, Peru, Samoa, Serbia and Montenegro, Thailand, and Tanzania) shows that the prevalence of intimate
partner violence varies greatly between different settings. The prevalence of physical violence ranges between
3% and 29%, and that of sexual violence between 1% and 59% (lifetime prevalence of physical violence ranges
between 13% and 61%, and of sexual violence between 6% and 59%). In general, urban settings in industrialized
countries reported the lowest prevalence, while rural settings in developing countries reported the highest.
120 Primary health care typically provides basic medical attention, and also focuses on preventive medicine and
health promotion (preferably, but not always, offered locally, close to where people live). Secondary health care
typically provides more specialized care, for example in hospitals. The tertiary sector offers care that is not
provided in the secondary sector, for example through specialized clinics. The health systems in the South have
generally developed over the years from a focus on secondary care (i.e. hospitals that often only served the needs
of the better-off citizens in the cities) to a focus on primary care, particularly after the Alma Ata meeting of 1978
and the “Health for all” declaration, mentioned earlier. The ambition thereby turned to providing a minimum
level of health services for all, even in rural areas. Multi-national drug companies also play a major role in
providing health care in the developing world today (Gatrell & Elliott 2009; Curtis 2004).
109
insurance. MINSA is also the primary supplier of health services for the first
and second levels of health care; consisting of health care centres and health
posts (which provide basic and preventive health care), and of departmental
hospitals (which provide curative care). MINSA’s service networks are
officially said to cover around 60% of the Nicaraguan population (PAHO
2009)121. Tertiary care is provided in national reference and speciality
hospitals located in the capital, Managua122 (Sequeira et al. 2011). The INSS
(Nicaraguan Social Security Institute) is in charge of the contributory sector,
which provides health care insurance and health services to workers in the
public and private formal sectors, together with other service networks
(MIGOB and MIDEF – the Military Health and Ministry of Government
Health Networks) that provide primarily curative services to active members
(e.g. military staff), as well as to other insured members (all insurance usually
covers part of family members’ health expenses as well). About 9% of the
population is insured, and the INSS (including the service networks MIGOB
and MIDEF) covers the health care for about 16% of the population (Muiser,
del Rocío Sáenz & Bermúdez 2011). The voluntary sector consists of private
actors (which provide health care services to those who can pay for health care
themselves), as well as non-governmental and other organizations (which
offer subsidized services to those who cannot afford to pay for health care)
(ibid.). The Nicaraguan health system is thus a mix of the two most common
models of health care: the “collectivist”/public model (which generally aims
for universal access to health care, based on the principle of need rather than
ability to pay, usually funded via income from taxes or compulsory insurance),
and the “anti-collectivist”/private model (which gives precedence to the
market, funded by private health insurance or by fees, paid by the user at the
point of use) (Gatrell & Elliott 2009; Anthamatten & Hazen 2011)123.
The Nicaraguan health care sector relies on primarily three types of resources.
Public funding constitutes a third (33%) of all contributions to the sector
(invested in the services of MINSA, MIGOB and MIDEF, as well as partly in
the INSS services). International cooperation (loans and donations) makes up
about 10% (invested in NGO services, for example). However, most resources
to the health sector come from households, whose out-of-pocket expenditures
are about 50% of all spending on health care (PAHO 2009) (in 2010, private
funds constituted almost the same share as the government’s expenditure on
health, i.e. 4-5% of GDP; UNDP 2013). These expenditures are used to pay for
121 However, most of the population supplements MINSA health care with services provided by private actors
or NGOs (PAHO 2009), as seen in the high amount of private expenditure on health care.
122 In 2008 there were 172 health care centres, 855 health posts, 21 departmental hospitals, and 11 national
reference and speciality hospitals (Sequeira et al. 2011).
123 As an effect of the structural adjustment programmes imposed by the WB and IMF during the 1990s,
Nicaragua – like other indebted countries – had to cut social spending, and in this process also enlarge the role
of the private sector in health care delivery (Gatrell & Elliott 2009).
110
health insurance, medical consultations, drugs, and treatment at both public
and private health establishments. The household expenditures on health
amount to between 16 and 19% of non-food expenditures (16% among the
poorest, and 19% among the richest) (PAHO 2009; Angel-Urdinola, Cortez &
Tanabe 2008). The largest part of the out-of-pocket expenditure on health is
spent on medication (72% in 2000-2004; PAHO 2009). Moreover, there are
substantial shortages of human resources and equipment, at both hospitals
and health care centres and health posts, especially in more remote areas.
During the period 2005-2010 there was only about one physician per 2,000
people (0.4/1,000), which is low in comparison with neighbouring countries
(UNDP 2013). The number of trained nurses is also low (Angel-Urdinola,
Cortez & Tanabe 2008), and only two-thirds (66%) of the population is
satisfied with the quality of health care (2007-09) (UNDP 2013).
There are substantial inequities in the access and use of health care services
in Nicaragua (Angel-Urdinola, Cortez & Tanabe 2008). Most of the health care
services are located on the Pacific coast, with the result that access to care,
particularly more specialized care, can be very limited in sparsely populated
areas (e.g. the Caribbean region). This is a common conflict within health care
systems, i.e. the difficulty of balancing efficiency with equity in planning and
resource allocation. While providers generally wish to manage resources
efficiently, often with a spatial concentration of services as a result, users often
desire a convenient and equal distribution of services. While the concentration
of services might seem unjust, the costs of travel for the user might in fact be
outweighed by the quality of services. In many countries, especially in the
Third World, there is consequently often regional variation in service
provision, with an urban bias (Gatrell & Elliott 2009). This is problematic
since there is evidence of a clear distance decay relationship between physical
distance from health services and health-seeking behaviour, meaning that
people living farther from health services seek health care more seldom, in
developing countries as well as others (see e.g. Muller et al. 1998, referred to
by Gatrell & Elliott 2009; and Feikin et al. 2009, referred to by Anthamatten
& Hazen 2011). The reasons behind this may be time-space constraints, and
costs in terms of time and travel, deterring people from seeking care.
However, it is not only physical distance that is important for people’s use of
health care. Social and cultural factors, for example, are also important for
people’s utilization patterns (ibid; see also Curtis 2004). In Nicaragua, there
also seems to be a distance decay effect (Angel-Urdinola, Cortez & Tanabe
2008). Additionally, individuals in the Pacific and Central regions are more
likely to seek and receive treatment than are residents in the Caribbean region
(probably due to the longer distances to health care facilities, but also to a
deficiency of services). Furthermore, there are also socio-economic inequities
in access to health care. Individuals belonging to households with higher
111
incomes, as well as higher educational level (completed primary and
secondary education), more often seek and receive treatment. Furthermore,
individuals with health insurance receive treatment twice as often as the noninsured. Moreover, the richer tend to use services of a higher quality (private
clinics, INSS services), while the poorer more commonly use public facilities
(health care centres, health posts) that are free-of-charge but often of poor
quality. In relation to the household expenditures on health, non-poor
households spend more on insurance, tests and hospitalization – thus items
related to better quality services – while poor households spend more on
medication (Angel-Urdinola, Cortez & Tanabe 2008).
Hence, the provision and utilization of health care services are influenced by
the applied model for health care. In Nicaragua, substantial deficiencies in the
country’s health care system result in socio-economic and geographical
inequities in health as well as in people’s access to health care. Part of the
health sector is public, and provides basic health care to all (free of charge).
However, as these services only provide the most basic services and often lack
resources, people are often forced to buy complementary – though often
necessary – services (such as x-rays, laboratory tests, etc.) from the privately
run services, or from the service networks that otherwise provide care for
members (employees, family members, privately insured, etc.). Moreover,
medicines are mostly paid for out-of-pocket, and constitute the largest part of
household expenditures on health. The health care system can thus be
described as non-inclusive, in the sense that people must invest a large share
of their private income in health care expenses, with the result that poorer and
less educated individuals receive treatment less often; and also because of the
concentration of services in urban areas, and in the Pacific area more
generally. As summarized by Angel-Urdinola, Cortez and Tanabe (2008):
Nicaragua’s health care system faces several main challenges that need to be
addressed in order to improve the health status of its population: (i) inefficiencies in
the allocation and utilization of resources, (ii) low levels of financial protection, (iii)
high out-of-pocket expenses for the poor, (iv) difficulties in access to and poor
utilization of health care services, and (v) an unregulated private sector and limited
capacity of MINSA to perform its stewardship role to ensure pro-poor strategies and
an efficient health system. Efforts to face these problems should be made within an
equity framework, since the poor and Indigenous populations have not widely
benefited from health gains. (Angel-Urdinola, Cortez & Tanabe 2008: 32)
Migration patterns
As described in the first half of this chapter, Nicaraguan migrations have deep
historical roots connected to centuries of regionalization and mutual
interdependence between the countries of the Central American Isthmus.
112
Similarly to the rest of Central America, Nicaragua has gone through three
migration phases during the 1900s; the first was when the number of
agricultural migrant workers as well as rural-urban migrants increased, in
relation to the “modernization” of agriculture that began in the 1950s. The two
latter phases are connected to international migration; the second involved
refugee movements and internal displacement due to armed conflicts and civil
war during the 1970s and 80s; and the third, which has been going on since
the late 1980s, is characterized by increasing internal and international labour
migration, in relation to the insertion of local economies into the “global”
economy, which has transformed the labour markets in the whole of Central
America. Hence, the number of intra-regional migrants has increased steadily
over the years, especially since the 1970s, and the character of the migrations
has changed from being mostly an internal matter to becoming increasingly
international. The motives for migration have generally been related to
economic and political issues – migration has thus been a way for people to
adapt to political and economic changes (Morales & Castro 2002).
Internal migration
The urbanization process in Nicaragua has been relatively slow, and the share
of the population living in urban areas is still below 60% (58% in 2012; UNDP
2013). A large share of the Nicaraguan population lives in the Pacific region of
the country (54% in 2005), nearly half (45%) in the capital, Managua, and
about 13% each in León and Chinandega. A third (32%) lives in the central and
northern areas, and 14% on the Caribbean Coast (INEC 2006). The
concentration of the population in the Pacific area began already in preColombian and colonial times, and continued with increasing force in
connection to the development of coffee and cotton production. The León area
drew particularly large numbers of people during this time, due to its
advantageous location and fertile lands (IOM 2013). The transformation of
the agricultural production system also led to seasonal labour migration; a
process that continues today. In relation to the decline in the agricultural
production since the 1980s, more people have moved into urban areas, where
other employment opportunities are higher (Morales & Castro 2002). The
Sandinista uprising and the Contra war that followed also produced an
internal displacement of rural populations, some of whom moved into urban
areas (Vivas Vivachica 2007).
The UNDP (2009) estimated for the year 2007 the number of lifetime internal
migrants in Nicaragua at 800,000 – equalling a migration rate (i.e. internal
migrants as percentage of the total population) of 13%. Vivas Vivachica (2007)
states that the number of lifetime internal migrants in Nicaragua is higher –
20% (based on census data from 1995 and 2005; including people moving
113
between municipalities). Furthermore, he states that 29% of Nicaraguans are
rural-urban migrants (this figure includes moves from rural to urban parts of
the same municipality). Compared to other Latin American countries these
numbers are low but this is definitely a notable amount, and has significantly
changed the profile of the country. In 2005, 8% had recently (in the past five
years) moved from rural to urban areas. The majority of rural-urban migrants
are female and low-educated (ibid.).
The agricultural base of the economy has made the Nicaraguan population
accustomed to moving from place to place in search of job opportunities
depending on the season. When the agricultural sector diminished (from the
1980s and onward), the “natural” next step for Nicaraguans was to migrate
abroad in search of work. As mentioned, other job opportunities besides those
connected to agricultural production were (and still are) lacking. Formal
employment is rare, and people are generally employed in the primary and
tertiary (informal) sectors. In the mid-1990s, people found it hard to earn a
living even in the informal sector, mainly because of the high number of
people depending on such work and low salaries, and partly as a result of the
structural adjustments. The rural population and women, in both urban and
rural settings, are those who have been affected the most negatively by the
harsh economic situation, with high emigration rates as a result (Morales &
Castro 2002).
International migration
The Nicaraguan migration connected to the second phase of Central American
migrations (see above) took place in relation to the long-lasting dictatorship
of the Somoza family, the revolutionary war that overthrew the dictator, and
the Contra war directed at the revolutionary Sandinista regime. During the
dictatorship some Nicaraguans fled the country, and during the uprising
against Somoza and the ensuing revolutionary war political dissidents left the
country, many seeking refuge abroad due to the armed war. In relation to the
Contra war, many took refuge and sought asylum in other countries (some
Sandinistas, questioning the way the revolution was headed, also left the
country during this period). In relation to the third phase of Central American
migrations, Nicaraguans have predominantly moved abroad, as the internal
labour market – including the informal market in the cities – has provided
few job opportunities. Due to the increasingly harsh living conditions,
particularly since the beginning of the 1990s, a large proportion of the
Nicaraguan population has thus been forced to emigrate in order to make a
living outside the country’s borders.
114
According to the most recent Nicaraguan population census (2005), the
number of emigrated citizens amounted to just under 170,000 (INEC 2006).
However, other estimates show that the number of Nicaraguan emigrants may
amount to between 600,000 and 800,000 (including undocumented
migrants). This represents about 10–13% of the total Nicaraguan population
(which in 2012 amounted to 6 million) (IOM 2013; UNDP 2013).
Furthermore, between 2005 and 2010 the net migration rate was -7/1,000
people (UNDP 2013). Besides these long-term emigrants, the IOM (2013)
estimates the number of temporary migrant workers, who predominantly
travel to neighbouring Central American countries (particularly to Costa
Rica), at about 1,000-2,000 per agricultural season. The majority (85%) of the
Nicaraguans who resided abroad in 2005 were aged between 15 and 64 years.
Jennings and Clarke (2005) also state that Nicaraguan emigrants are often of
working age and, furthermore, that they are more often well-educated and
working in skilled jobs (white-collar workers) than non-migrating
Nicaraguans. Moreover, those migrating to Costa Rica are more often women
from urban areas and with higher education, and are not primarily loweducated agricultural workers as is commonly assumed. Due to this,
remittances tend to be received among families in the lower and middle
classes rather than the extremely poor (ibid., with reference to Orozco 2003).
As mentioned earlier in the text, Costa Rica and the US are the two most
important destinations for Nicaraguan emigrants). According to the Costa
Rican census of 2011, just under 290,000 Nicaraguans resided in the country
(which is close to 50% of all Nicaraguan emigrants, and amounts to nearly 7%
of the total population, and three quarters of all immigrants, in Costa Rica)
(for 2010 the World Bank estimates the number of Nicaraguans in Costa Rica
at even more – over 370,000; IOM 2013). There is a history of mutual
interdependence between Nicaragua and Costa Rica. The migration patterns
in modern days can therefore be seen as a continuation of the economic,
political and societal practices of the past. Nicaraguans in need of a means for
survival have long turned to Costa Rica, where employers have been in need
of labour power. The labour markets of the two countries are not each other’s
competitors; instead, they constitute two complementary parts within the
same transnational labour market. The incorporation of Nicaraguans into the
Costa Rican labour force began at the end of the 1800s when Costa Rican
agriculture, e.g. banana plantations, and industries were in need of labour
power. Almost a century later, in the 1980s and 90s, when Nicaragua was
facing difficulties in agricultural production, due to falling world market
prices on important export products such as cotton, and as other industries
had not been sufficiently developed to absorb the labour force, Costa Rica was
again seen as an alternative labour market. Costa Rica, in turn, has had (and
continues to have) a need for Nicaraguans willing to work in sectors where it
115
is hard to employ Costa Ricans124. Costa Rican employers may also prefer to
employ Nicaraguans, because of the possibility to give them “lesser pay for
harder work” (especially if they are irregular immigrants, lacking legal rights).
Moreover, women in Costa Rica are increasingly taking part in the labour
market. This has opened up new possibilities for employment for Nicaraguan
women, who assume the responsibility for household work (Morales & Castro
2002); i.e. a “transnationalization of reproductive labour” (e.g. Ehrenreich &
Hochschild 2002), which produces “global care chains” (e.g. Hochschild
2000).
Costa Rica has historically had an openness to refugees and other migrant
populations, but a marked shift towards more restrictive immigration policies
has taken place since the beginning of the 21st century, like in many countries
in the North (especially in the US after 9/11). In 2006, a new immigration law
was passed in Costa Rica, which dramatically limited the opportunities for
Nicaraguans to live and work legally in Costa Rica125. The country has also
expanded police and border control (Fouratt 2014). The law was criticized for
human rights violations and successively reformed as to correct
inconsistencies and soften its repressive tone. A new law was passed in 2009;
however, it was still aimed at restriciting legal immigration and eliminating
“illegal” immigration (for example by exercising high fines for being “illegal”).
In practice, when travelling to Costa Rica, Nicaraguans are required to have a
passport and to pay for a tourist visa. Temporary work has to be applied for
by the employer.
The number of Nicaraguans residing in the US are rather similar to those in
Costa Rica: between 247,000 and 348,000, depending on the source (IOM
2013), which represents about 40% of all Nicaraguan emigrants. Massey and
Sana (2003) estimate that only 14% of Nicaraguans are documented on their
first trip to the US, while over half (58%) are documented on later trips; a large
share of Nicaraguans in the US are consequently undocumented126, lacking
the rights connected to citizenship or residence. Many US-Nicaraguans live in
Miami (Hamilton & Chinchilla 1991). Neighbouring countries in Central
America (Honduras, El Salvador, Panama and Guatemala), as well as Spain,
124 Nicaraguans mostly work in agricultural production (coffee, banana, sugar), construction and industry
(textile), and as domestic servants (women) and security guards (men).
125 For example, it became much more difficult to acquire residency as the cost and necessary administrative
work increased dramatically. This proved difficult as the registry system in Nicaragua is very ineffective – in
order to obtain a national ID card Nicaraguans have to complete a 52-step process. Moreover, many lack
necessary certificates; in parts of Nicaragua 50% of all births go unregistered, and many have also lost their
birth or marriage certificates due to the war. Even though Nicaraguans may be entitled to residency in Costa
Rica, for example if one child has been born in Costa Rica, many are thus unable to apply for it (Fouratt 2014).
126 Donato et al. (2005) state that a quarter of Nicaraguans and Dominicans (mean for both countries) in the
US were undocumented on their last trip.
116
are other important destinations, that have risen in importance during the
beginning of the 2000s. Yet, the shares of the Nicaraguan migrant population
in these countries are rather modest. In 2010 approximately 6,000, 10,000,
and 16,000 Nicaraguans moved to El Salvador, Panama, and Spain,
respectively (IOM 2013). Since 2004 there has been an agreement between
Nicaragua and the three other so-called CA-4 countries (El Salvador,
Honduras and Guatemala) that grants citizens the right to move freely
throughout the member countries without a passport. However, a national
identification card is required, the time limit to stay is six months, and
authorization is required in order to work. If one does not fulfil the necessary
requirements, deportation may follow. In 2009, for example, Guatemala
deported 187 Nicaraguans who were working illegally (Alba & Castillo 2012).
In 2005, the share of male emigrants was slightly higher than that of female
emigrants (53% and 47%, respectively) (IOM 2013). Yet, the “feminization” of
migration – which is visible around the world today – has also recently
introduced itself in the case of Nicaraguan international migration. In 2011,
female emigrants outnumbered male emigrants in some destinations,
particularly Spain (where 75% of all Nicaraguan immigrants were female) and
Panama (where 59% were female). In Costa Rica 55% were females, and in the
US 54%.
In sum, migration is a predominant feature of Nicaraguan society.
Contemporary Nicaraguan migration patterns have deep historical roots.
Migration has gone from being mostly an internal and regional matter to an
increasingly international process. The motivations for migration have been
influenced by a mix of economic, political and socio-cultural factors. Internal
migration consists mostly of movements from rural to urban areas, or of
seasonal labour migration connected to agricultural production. Overall,
people make their living within the informal sector, agriculture and
manufacturing. The difficult economic and social situation in Nicaragua has
forced many men and women to also emigrate in search of employment
(especially after the 1980s when the agricultural sector went into decline, and
after the 1990s when neo-liberal policies were introduced, which led to high
levels of unemployment). About 10-20% of the population currently resides
abroad, primarily in Costa Rica and the US, but also in other countries in
Central America as well as in Canada, and Europe. The remittances the
migrants send home to their family members who are left behind constitute a
large part of the country’s gross domestic product, and are an important
source of income for many families. However, as Nicaraguan emigrants often
come from lower- and middle-class households, remittances tend not to go to
the poorest in society.
117
The study settings of León and Cuatro Santos
As mentioned, this study was conducted in the town of León, situated in the
Pacific coast area, and in Cuatro Santos, four municipalities in the northern
part of Chinandega (see Figure 1, p. x). According to the latest census,
conducted in 2005, León municipality has a population of approximately
191,000, of whom 81% live in the urban parts of the municipality. It is the
second largest town in Nicaragua, but nevertheless hosts only 3.3% of the
country’s total population (INIDE 2007a). The Cuatro Santos area has nearly
27,000 inhabitants, of whom 83% live in rural areas. San Pedro is the least
populated of the four municipalities included in the area (with just under
5,000 inhabitants), while Santo Tomás is the most populated (almost 8,000
inhabitants).
León is thus primarily an urban area127, while Cuatro Santos is predominantly
rural. The urban/rural character of the areas produces great differences that
are worthy of noting. For example, in the year 2000 the HDI of Cuatro Santos
was only 70% of that of León (0.52 compared to 0.74)128 (UNDP 2002). These
differences in HDI reflect that people in Cuatro Santos are generally poorer
than those in León. In fact, in 2005, while almost half (47%) of the population
in Cuatro Santos endured extreme poverty, just under one-fifth (19.7%) in
León municipality were extremely poor (INIDE, homepage, data accessed
2013-11-28). The HDI furthermore indicates that more Cuatro Santos
inhabitants are illiterate, and that fewer children in this area attend school
compared to León. The higher HDI in León also indicates that the León
population live healthier, longer lives than do those living in Cuatro Santos.
Progress has been made toward meeting the MDGs in both León and Cuatro
Santos, but substantial problems still exist. Wilton Pérez (2012) shows that
under-five mortality (MDG4) was reduced by 60% in urban León, by 45% in
rural León, and by 36% in Cuatro Santos between 1990 and 2005. He points
out that particularly neonatal mortality must decrease in León and Cuatro
Santos in order for MDG4 to be achieved (in León the under-five mortality in
the neonatal period in fact doubled between 1970 and 2005). Social
inequalities must also be addressed, according to Pérez; particularly the
education of mothers, which influences child health to a high degree, and
rural-urban divides, in terms of living conditions and health care delivery.
Regarding MDG1 in Cuatro Santos, Pérez shows that poverty was widespread,
even higher than on the national level, but that the levels of poverty and
127 Moreover, only urban households in León were included in the survey study, and all interviewees also lived
in the urban parts of the municipality.
128 There were also differences within the area of Cuatro Santos that are important to acknowledge: the HDI
was the lowest in Santo Tomás (0.49), and the highest in Cinco Pinos (0.57) (UNDP 2002).
118
extreme poverty were greatly reduced – by 13% and 5%, respectively –
between the years 2004 and 2009. He further states that rural areas have
generally shown greater improvement in the reduction of poverty than urban
areas have.
The patterns of migration in León and Cuatro Santos have been discussed
throughout the chapter, and will thus here be only briefly summarized and
somewhat extended. The department of León has historically been an area of
in-migration, especially in relation to the cotton production developed there
because of its favourable location and fertile lands (IOM 2013). When the
decline in cotton and other agricultural production took place in the 1980s,
more people moved into the urban areas (Morales & Castro 2002). In Cuatro
Santos, predominantly a rural area, the agricultural production system
installed in Nicaragua since colonial times often involves seasonal labour
migrations. When the agricultural sector was diminished (from the 1980s and
onwards), emigration rose in rural areas, as well as in urban areas where other
job opportunities were few. In 2005, more than two of ten Nicaraguan
emigrants originated from one of the two settings of this study – the
departments of León and Chinandega (11% each) (IOM 2013). (Over a quarter
– 26% – originated from the department of the capital, Managua). Half of all
Nicaraguan emigrants residing in El Salvador originated from Chinandega
(while slightly over 40% of all Nicaraguans in the US, and about a third of all
Nicaraguans in Panama, came from the department of Managua). Almost 14%
of all Nicaraguans in Costa Rica originated from the León area (10% from
Chinandega). Furthermore, about 8% of Nicaraguans in the US came from one
of the two settings of this study.
Summary
Nicaragua has thus gone through many different phases during its past and
more modern history – colonialism, post-independence political chaos,
dictatorship, revolution, and neo-liberal and socialist governments. Profound
socio-economic transformations have taken place, and the country’s
migration patterns and health trends have also changed in relation to this.
The colonial era led to an externally oriented agricultural economy, patterns
of dependence, and elite rule. Seasonal labour migrations began during these
times, when the agricultural structure was transformed. After independence
the seasonal labour migrations continued, particularly in relation to the
increase in coffee production (from the late 1800s). When banana production
rose in neighbouring countries (Honduras, Costa Rica), this also led to the
seasonal emigration of Nicaraguan agricultural workers. The post-
119
independence era was also characterized by internal conflicts, civil war, and
foreign dominance. In the quest to build a canal across the isthmus, the US
made several political intrusions in Nicaragua (from the 1850s), which
culminated in a 20-year occupation (in the 1920s and 30s). The US also
supported the Conservative party, and continued to do so when power had
been seized by Somoza, whose family’s dictatorship lasted 40 years (19361979). During these years, the majority of the Nicaraguan population was
politically repressed and the elite became vastly corrupt. Still, economic
growth and important development took place in the country; however, the
benefits were mostly enjoyed by the wealthier social groups. During the
expansion of agriculture, especially cotton production, beginning in the 1950s,
more became seasonal migrant workers. The concentration of this production
in the Pacific and Central regions also led to in-migration to these areas. Many
moved into urban areas because they had lost their lands or found it hard to
make a living as small-scale farmers. The urbanization process thus began.
Due to the political and socio-economic situation (the foreign debt had
increased substantially) the Sandinistas’ war of liberation was initiated, and
in 1979 the Somoza dictatorship came to an end. The revolution had high
socio-economic costs. Many were internally displaced, or sought refuge in
Costa Rica or the US. The new government nevertheless managed to
accomplish a slow economic growth (largely thanks to international
cooperation) and initiate reforms to improve the situation for the poor
Nicaraguan population. For example, the health care system was vastly
improved, and wide-ranging vaccination and literacy campaigns were carried
out. Infant mortality continued to decrease, and life expectancy increased. The
literacy level was also substantially improved. However, the Contra war
initiated against the Sandinistas had large-scale socio-economic costs. As
during the revolution, many were internally displaced, or sought refuge
abroad (primarily in Costa Rica and the US). In 1989 about 100,000
Nicaraguans lived in Costa Rica, and by 1990, almost 170,000 Nicaraguans
were officially registered in the US. The economic situation became even more
difficult to handle, due to the global recession and the serious debt crisis that
followed. Cuts in economic and social programmes were a necessity, which led
to higher unemployment and aggravated poverty. Due to the economic
collapse, harsh living conditions, the exhausting Contra war, and increasing
political instability, the revolutionary years came to an end and were followed
by two decades of conservative governments, characterized by neo-liberal
policies and corruption scandals. Structural adjustment programmes were
initiated, aiming to stabilize the economy, which led to higher levels of
unemployment and poverty, and a backlash for social improvements (e.g.
access to health care, and literacy levels). As a consequence of the
deteriorating living conditions during the 1990s, more and more Nicaraguans
sought better opportunities abroad. The debt situation also became
120
unmanageable, and in the 2000s Nicaragua was admitted to the HIPC
initiative, through which a large part of the country’s debt was cancelled. The
socio-economic situation for the Nicaraguan population at large, however, did
not improve to any greater extent. Emigration continued, and by the turn of
the century almost 500,000 Nicaraguans were living abroad (about half each
in Costa Rica and the US) (IOM 2013). Due to the difficult living conditions,
and because of the conservative parties’ weakened position, the Sandinistas
were voted back into power in 2006. Because of the weak economy, however,
the Sandinistas have not been able to change the socio-economic situation or
living conditions as much as planned. Even though the country has
experienced positive economic growth and a slow but steady increase in HDI
in recent years, it is still at a medium level of development, characterized by
widespread poverty, low educational levels, large agricultural and informal
sectors, little formal employment and a high degree of underemployment, low
income levels, and high degrees of school dropout and child labour. Large
differences in socio-economic status still exist between men and women, rural
and urban areas, and the country’s different regions. While improvements in
health indicators have certainly continued to be achieved, Nicaragua will have
difficulty reaching the health-related MDGs (especially concerning maternal
and child mortality). Although progress has been made, and the government’s
expenditure on health is at a reasonable level, there are substantial socioeconomic and geographical inequities in health as well as in people’s access to
health care. Households pay for half of all health care costs themselves –
primarily for medication, but also for health insurance, medical consultations,
and treatment at both public and private health establishments. The health
care system can thus be described as non-inclusive, and vast differences exist
between different social groups and different geographical locations. Seasonal
labour migration continues, as does emigration to Costa Rica and the US.
Some new migration trends have also emerged – increasing emigration to
other Central American countries (primarily El Salvador and Panama) and to
Spain. In relation to this, the country is receiving higher amounts of
remittances than ever before (representing more than 10% of the GDP), which
are mostly used for consumption, health care and education. The optimism
felt among the population when the former revolutionary leader Daniel Ortega
was elected has faded over the years, partly due to President Ortega’s
increasingly authoritarian rule and corruption of the rule of law.
On the next page follows an overview of key events, and demographic as well
as socio-economic indicators, in the modern history of Nicaragua. The
empirical part of the thesis then takes on.
121
Table 7: Nicaragua’s modern history; selected indicators and major events.
Population
(in thousands)
Urbanization rate
GDP per capita
(US$)
Remittances
(US$, millions)
HDI a
1,300
(1950)
23-39%
(1960)
$231
(1950)
0.381
(1950)
Poverty level b
Expenditure on
educationc
Literacy level
Expenditure on
healthc
Life expectancy
(in years)
Fertility rate
Maternal
mortality rated
Infant mortality
ratee
$999
(1975)
0.569
(1975)
40%
(1977-86)
1%
(1960)
38%
(1950)
0.4%
(1960)
61%
(1979)
3.2%
(1980)
42 (1950)
55 (1975)
7.2
(1950)
3,100
(1980)
50%
(1980)
$611*
(1985)
0.461
(1980)
$419
(1993)
$75
(1995)
0.496
(1990)
50%
(1989-94)
6%
(1986)
88%
(1988)
6% (1986)
1% (1990)
$452
(1998)
$435
(2000)
0.529
(2000)
80%
(1990-03)
63%
(1997)
4%
(1996-98)
6,000
(2012)
57%
(2010)
$1,470
(2006-12)
$913
(2011)
0.593
(2010)
48%
(2005)
4-5%**
(2000-10)
78%
(2005-10)
4-5%
(2009)
64 (1987)
74 (2012)
6.3 (1980)
2.5 (2012)
95 (2010)
140-180
(1950)
70-90
(1979)
61 (1988)
23 (2010)
a) Human Development Index; b) % living on less than US$2 per day; c) % of GNI; d) deaths per 100,000 live
births; e) deaths per 1,000 live births; *) GNI per capita **) % of GDP
Major events
Somoza dictatorship Sandinista revolution Conservative era FSLN re-elected
(1936-79)
(1960-1979)
(1990-2006)
(2006)
Managua earthquake First democratic election SAPs
(1972)
(1984)
Contra war Hurricane Mitch (1998)
122
PART II:
RESULTS FROM THE
EMPIRICAL MATERIAL
This part of the thesis presents in a combined manner the findings
of the qualitative and quantitative studies. Chapter 5 (“Mobile
livelihoods and health dynamics”) is dedicated to the analysis of
migration, and the entanglement of health in the process of
migration. Chapter 6 (“Health on the move”) analyses the
consequences of migration and implications on health from the
migrant’s perspective. Chapter 7 (“Coping with translocal lives”)
deals with migration-induced changes in social relations and the
implications on health thereof. First follows a short introduction
in which I explain how I have organized the text in the three
empirical chapters.
Street view, León.
123
León public hospital.
Health care centre, Cuatro Santos. Photo: Mariela Contreras.
Advertisment at shopping centre for money transfer agent, León.
124
Introduction to the empirical chapters
The empirical chapters are structured thematically around the main findings
of the interview study. The qualitative findings form the basic foundation for
the analysis of the survey data. The quantitative study provides statistical
background information, illustrates the magnitude of certain aspects, and
investigates specific associations between migration and health that were
salient in the qualitative study.
The complexity of migration-health relations
The interview study clearly showed that the relation between migration and
health was of a complex and multidimensional nature. The migration events
and the resulting changes in life that the interviewees talked about entailed
both gains and losses (benefits and costs); that is, both positive and negative
consequences for health of both a direct and indirect character. Additionally,
health problems or health concerns could both directly and indirectly
influence the decision to move away, stay, or return. Just as one and the same
interviewee could have many different experiences of migration (as an
internal and/or international migrant, and/or as having been left behind by a
migrating family member), one and the same person could also express a
variety of ways migration and health were interconnected in his/her particular
case. A central conclusion of this study is therefore that it is important to
acknowledge the blurring of migration categories in analyses of the relations
between health and migration. The biographical approach proved to be very
useful for understanding and analysing these complexities, because it allowed
the processual and relational nature of migration – and the ways the
migration-health nexus was enacted over time and space – to be understood
as part of the person’s migration biography.
Mobile livelihoods, migrant health and translocal lives
The qualitative interviews were also analysed by means of constructivist
grounded theory (CGT), in an abductive process in which I switched between
the grounded analysis of the interview material on the one hand and readings
of theoretical approaches and previous research on the other. In the analytical
process I identified three overarching themes – mobile livelihoods, migrant
health and translocal lives – that each embraced different aspects of
migration-health relations in the material. These themes are thus grounded in
the empirical material, and are also existing concepts discussed in previous
literature. Each theme is given prominence in one of the three succeeding
empirical chapters included in this part of the thesis. Furthermore, each
125
theme builds on a number of sub-themes (sub-categories) that were identified
in the CGT analysis. For example, the first theme (mobile livelihoods) includes
the sub-theme “health-related motivations for migration/non-migration”, the
second (migrant health) includes the sub-theme of “living and working
conditions”, and the third (translocal lives) includes the sub-theme of “effects
on family relations”. The sub-themes constitute sub-headings in the
succeeding chapters.
Vulnerability, suffering and coping
In the CGT analysis I also identified three key aspects that were salient across
all interviews – vulnerability, suffering and coping. The category
“vulnerability” encompassed, for example, the aspects of poverty,
precariousness, and undocumentedness. The category “suffering” comprised
(e.g.) negative health effects of migration. Lastly, “coping” grasped the ways
in which the interviewees handled difficulties that arose due to, for example,
poverty and migration. As these sub-themes were important to all three of the
above-mentioned overarching themes, they are discussed in all three
empirical chapters. Even though all the interviewees’ life stories contained
elements of the three key categories, the degree of vulnerability and of
suffering varied a great deal depending on the personal context. Some
interviewees were thus in a more vulnerable situation than others, and some
had endured more suffering than others, which naturally influenced the
enactment of the migration-health nexus. Coping mechanisms were,
moreover, more or less explicit in the interviews and important to the
interviewees. The importance of contextualization and acknowledgement of
social differences are therefore other significant conclusions of the study.
126
CHAPTER FIVE
Mobile livelihoods and health dynamics
Introduction
As described above, Nicaraguan migrations have deep historical roots
connected to centuries of colonization, neocolonization and interdependences
between the countries of the Central American Isthmus. Migration has been a
way for people to adapt to political and economic changes (Morales & Castro
2002). With the modernization of agriculture that began in the 1950s, the
number of agricultural migrant workers as well as rural-urban migrants
increased in Nicaragua. The long-lasting dictatorship of the Somoza family,
the revolutionary war and the Contra war caused a great deal of internal
displacement, with political dissidents and war refugees fleeing the country,
primarily to neighbouring countries or the US. Since the late 1980s,
Nicaraguans have predominantly moved abroad in order to make a living
outside the country’s borders. Remittances are an important source of income
for investments in health care and education, in a situation with a downsized
public sector and “absent or failed forms of state care or public services”
(Fouratt 2014: 56). The concept of “mobile livelihoods” (e.g. Olwig & Sørensen
2002) highlights the embeddedness of migration in people’s strategies for
making a living, and captures many of the features encountered in the study
context.
This chapter aims to analyse the character of mobile livelihoods in the
Nicaraguan case, and particularly to examine how health issues are embedded
in people’s mobile livelihoods, as they are expressed in the interview and
survey material. The chapter is related to all three of the thesis’ research
questions, but most importantly to the first and second questions: How can
the dynamics between migration and health be understood in the
Nicaraguan context? In what ways do health issues influence Nicaraguan
men’s and women’s migration strategies? It particularly tries to respond to
how health concerns are integrated into motives for migration, staying and
returning, for what reasons remittances are sent, and how health issues are
related to these remittance patterns. The chapter considers both migrants’ and
left-behinds’ accounts of the entire process of migration – health issues are
thus traced within the migration process, within the practice of mobile
livelihoods. This is based on the understanding that migration is of a relational
and processual nature, including and linking different actors, places, spaces
127
and scales – thus creating “translocal geographies” (Brickell & Datta 2011). In
the thesis I make use of the frameworks developed by Haour-Knipe (2013) and
Zimmerman, Kiss and Hossain (2011), according to which migration-health
relations should be analysed in the different phases and places included in the
migration process – the origin (pre-departure and return conditions), the
transit (conditions during travel), and the destination (the reception, etc.).
This chapter focuses primarily on the conditions in the origin (i.e. Nicaragua)
(although it also mentions other phases and places included in the migration
process). Moreover, I examine both how migration affects health and how
health affects migration; hence, I assess the bi-directional character of the
migration-health nexus in my material. The idea of social capital (e.g. social
support) and the migration-development nexus (see Chapters 1 and 2) are
discussed in the chapter in relation to remittances.
The chapter presents results from both the interview and survey data. The text
is structured around the findings of the qualitative study, and the
themes/categories identified in the qualitative analysis are presented
embedded in the biographies of the interviewees, which show the connections
to changes and varying circumstances over the life course. In the chapter the
survey data are used in describing the migration patterns in the two study
areas, to illustrate certain aspects that were central in the interviews, and to
investigate certain associations between migration and health. The first
section of the chapter discusses the study participants’129 prior experiences of
migration (migration biographies/histories and migration/translocal
networks). This will serve as a background for the next section on motivations
for migration (staying and returning) and intentions for future migration. The
third section discusses exchanges of help within social networks (social
support, remittances) and their relations to health. Lastly, a summary of the
chapter’s main findings is provided.
Prior experiences of migration
Research on migration dynamics shows how migrant networks are crucial for
the emergence, unfolding and upholding of migration systems (Faist 2000;
Glick Schiller & Faist 2010; Portes, Guarnizo & Landolt 1999; Tollefsen
Altamirano 2000). Migration systems expose particular spatial patterns,
conditioned on identifiable structural factors; in Nicaragua’s case, the
historical experience of colonialism and dependency and, more recently, the
“globalized” labour market and enforced structural adjustments. The
dynamics of migrations under these conditions depend largely on the strength
129 By “study participants” I mean both the interviewees and the survey respondents.
128
and character of migrant networks; how they are sustained and/or broken,
how they change over time, and how they influence new generations of
migrants, i.e. how transnational dynamics evolve (Glick Schiller, Basch &
Blanc-Szanton 1992; Portes, Guarnizo & Landolt 1999; Faist 2000; Levitt &
Glick Schiller 2004; Tollefsen & Lindgren 2006; Vertovec 2009; Glick Schiller
& Faist 2010). In the in-depth interviews as well as the survey data, migrant
networks were salient features and also varied in extent, character and
functionality.
Qualitative results: migration biographies and networks
The interview study included individuals with many different experiences of
migration – persons who had moved internally, and/or internationally, as well
as those who were family members of migrants (i.e. left-behinds) (see Table 1,
p. 56, and the accounts of the interviewees thereafter). Several of the
interviewees also expressed thoughts about moving elsewhere, and some had
very specific plans to move. However, about half of the interviewees did not
express any plans to move. The interviewees’ past experiences of migration
and intentions to move in the future will be discussed further throughout this
chapter, as well as in the succeeding chapters. For now, I will settle with saying
that the interviews provided several illustrations of the blurring of migration
categories. One and the same person could have experiences of both internal
and international migration (and of leaving family members behind), as well
as of being left behind by a migrating family member. Rosa’s migration
biography below shows us how distinct migrant categories can be problematic,
given the complexity of migration-health relations during the life course.
Overlapping migrant categories – Rosa’s story
Despite her young age, Rosa (27 years) had a very rich life history, filled with
dramatic events. She was born in León, and subsequently moved with her
mother and siblings to a rural area outside León when she was four years old.
A volcano eruption forced the family to move again when Rosa was eleven –
this time to a small town in the Chinandega province (north of León). At the
age of 16, Rosa went to Costa Rica for the first time, undocumented, along with
her husband. They returned when it was time for her to give birth to their first
child. During their second trip to the country, they left this child in the care of
relatives. Two years later Rosa and her husband returned once again to
Nicaragua, because she was expecting their second child. Rosa mostly worked
as a live-in maid during the trips to Costa Rica, and highlights in the interview
that, because she lived with her employers, and thanks to her “whiteness”, she
was hidden from the authorities and the Costa Ricans’ gaze, and was therefore
129
in a less vulnerable situation than others, which lessened her suffering. In
1998, Rosa’s husband died unexpectedly when Hurricane Mitch struck
Nicaragua. She and her two small children then moved to an area closer to
León, where she could receive humanitarian aid. After two difficult years in a
provisional settlement, Rosa and her children received a plot of land and
construction material to build a house. By then she had fallen in love with a
new man, with whom she had another child. After 18 months he decided –
with Rosa’s approval – to go to Costa Rica. Although her husband promised
not to “forget” Rosa and the children, she did not hear a word from him for
three years. During these years, Rosa went once more to Costa Rica (for seven
months) and to Managua (for one month), while her children stayed with her
mother. Her youngest son suffered a great deal from the separation, and also
due to his father’s abandonment. Shortly after her return from Managua Rosa
had the opportunity to work at a hotel at the coast, which is where she was
working at the time of the interview. Her children continued living with her
mother, as Rosa worked long hours at the hotel. Due to the long distance to
her mother’s house, Rosa could only visit her children one day a month. In the
interview, she said she did not want to go to Costa Rica or Managua to work
again but rather preferred to stay in León, although the distance from her
children was a bit too far. In 2013, when I saw Rosa last, she was still working
at the hotel. However, her children and her mother had moved to Rosa’s
house, which was located a bit closer to León and about a half-day’s trip from
her workplace, which made it possible for her to see them more often.
Rosa’s story is interesting for several reasons. First of all, it captures both
internal and international migration experiences, in relation to both job
search and natural disasters, and illustrates how migration is embedded in the
strategies for making a living (thus an example of the practice of mobile
livelihoods). Moreover, the unpredictable nature conditions in Nicaragua and
their effects on health and people’s settlement patterns are also captured in
her story, as well as the importance of humanitarian aid. South-south
migration, care work, and vulnerability (as regards poverty and the
environment as well as migration) – in relation to social differentiations
(immigration status, skin colour, and gender) – are also highlighted in her
story. The relation between reproductive health and migration is also
captured, in Rosa’s returning to Nicaragua to give birth. Her story also
demonstrates how translocal lives, and the separation they entail, can be
experienced (being left behind, abandoned, and living separated from one’s
children). The effects on family relations and child health are also seen in
Rosa’s story. Lastly, the blurring of migration experiences and the complexity
of migration-health relations during the life course (a central finding in this
study) are clearly seen in Rosa’s story.
130
Migration networks
Most of the interviewees had family members (including extended family;
here also called relatives) and friends who lived in other places. The extent of
these migration/translocal networks naturally varied greatly. Some had
family members only in other parts of Nicaragua, and some only abroad, while
some had relatives both in Nicaragua and abroad. The interviewees who were
born in other parts of Nicaragua, and who had subsequently moved within the
country, often had relatives (and/or close friends) in their birthplace with
whom they stayed in contact (Sandra in Chinandega, Rosa in a rural area
north of León, and Marta, Mercedes and Orlando outside León). One
interviewee had all her relatives in her birthplace (Ana). About half of the
interviewees had family members in the biggest cities of Nicaragua (Grenada,
Managua, or León). Besides these internal networks, 14 interviewees had
relatives (and/or close friends) abroad: in eight cases (Cindy, Juliano,
Joanna, Carmen, Rosa, Fernando, Santos, Esmeralda) in one other country;
three (Sandra, Gloria, Maribel) in two other countries; one (Marta) in three
other countries, one (Aleyda) in four other countries, and one (Cesar) in five
other countries.
Survey results: migration networks, migration histories and
intentions for future migration
The survey study showed, similarly to the interviews, that wide-reaching
translocal networks were common in the study population. In the sample
frame created in Step 1 of the survey study (consisting of 19,058 individuals),
a third (34%) had family members living in other places (in Nicaragua or
abroad)130. In the second step of the survey (hereafter also called Survey
2008), the issue of migration/translocal networks was investigated further.
This was done both in order to see the magnitude of these networks, but more
importantly, in order to use this information in the coming analysis of
migration-health relations, e.g. health effects of family dispersal, based on the
idea that migration might cause changes in social networks that may be
important for health (see the section “Social support, remittances and
health”).
In the survey, the respondent was therefore asked if he/she had any family
members (including extended family; here also called relatives) living in other
130 Almost 15% (6,309 individuals) of those in the sample frame were categorized as Left-behinds in the process
of creating a sample for the second step of the survey; that is, they had at least one out-migrated family member,
but had no personal records of migration in the HDSS data. The others were categorized as either Non-mover
(62%) or In-migrant (3.7%), based on migration events in the HDSS (see Chapter 3 for information about the
survey study design, and Table 2 on p. 72).
131
places, who they were, and where they were located (Questions 6-7, Survey
2008; see Appendix). The results showed that a vast majority (89%)131 of the
survey respondents (including 1,383 individuals in total132) had relatives
living in other places in Nicaragua or abroad. Many of these had large
migration networks – over a quarter (28%) had between five and ten family
members in other places, and 17 % had eleven or more dispersed family
members. Just over half of the respondents (54%) had smaller networks (1-4
family members in other places)133. Regarding who lived in other places, few
(2%) claimed to have their partner living in another place (see Figure 6).
However, this low figure might be related to how the question was posed, or
how the respondent interpreted the question (i.e. not mentioning their
partner but only more distant relatives). Almost two-thirds (62%) reported
having their siblings in other places, and many also mentioned other relatives
(57%) (e.g. aunts, uncles, or cousins). Around a quarter each mentioned
children (26%) and parents (24%), and 14% mentioned grandparents.
(has family members in other places=88,7 %)
80
60
62
57,4
40
25,8
23,5
20
14,2
1,7
0
Sibling
Other relative
Child
Parent
Grandparent
Partner
Figure 6: Family members in other places (who). Weighted percentages.
Based on Questions 6-7, Survey 2008 (see Appendix).
Regarding where the dispersed family members were located, the survey
showed that many respondents’ relatives lived rather close by – in the same
municipality (mentioned by 26% of respondents) or in another municipality
(34%) (Table 8, next page). Nevertheless, more than a third (35%) of the
respondents had family members in another department, and over two-thirds
(68%) had relatives abroad. A statistically significant difference between the
two settings was that the respondents in León more often had relatives within
the same municipality, and that those in Cuatro Santos more often had family
131 Weighted values. All values in the text based on responses from the survey are weighted values, unless stated
otherwise.
132 Unweighted count, excluding non-responses.
133 In the subsequent regression analysis, respondents with zero to four family members in other places were
categorized as having “few” relatives in other places (also called “small migration network”), while those with
five or more relatives in other places were categorized as having “many” relatives in other places (“large
migration network”).
132
members in another municipality. This is to be expected, due to the
urban/rural character of the two study settings.
Table 8: Location of dispersed family members
All respondents
León
Cuatro Santos
In the same municipality
25.9%
65.5% a
8.9% a
In another municipality
34.4%
13.6% a
43.3% a
In another department
35.4%
38.7%
34.0%
In another country
67.6%
71.7%
65.8%
Notes: Based on Questions 6-7, Survey 2008. Weighted percentages. Statistical significance of
crosstabulations tested with Pearson Chi-Square; a p<o.001.
Furthermore, regarding those who had family members residing abroad, over
four of ten (42%) stated that their relatives lived in Costa Rica, and almost a
third (31%) had relatives in the US (Figure 7). Moreover, over a quarter (26%)
had relatives in Honduras, and a fifth (20%) in El Salvador. These results are
similar to national figures on the whereabouts of Nicaraguan emigrants,
according to which Costa Rica and the US are the two most common
destinations (see e.g. IOM 2013).
50
42
40
(has family members abroad=67,6 %)
30,8
26,1
30
20,5
20
10
0
Costa Rica
USA
Honduras
El Salvador
Figure 7: Family members abroad (country of residence).
Weighted percentages. Based on Question 7, Survey 2008.
Inhabitants in Cuatro Santos more often had family members in Honduras
(38% of respondents, compared to 1% in León) and El Salvador (28%
compared to 5% in León)134, while León inhabitants more commonly had
relatives in Costa Rica (54% of respondents, compared to 37% in C. Santos)
and the US (42% compared to 26% in C. Santos)135. This is rather unsurprising
due to the geographical proximity between Cuatro Santos and the two
countries to the north (Honduras and El Salvador), and between León and
Costa Rica. Since the population in León generally has a better socio-economic
134 p>0.001.
135 p>0.01.
133
situation, it is also to be expected that more move to the US from this area.
Our findings are similar to other figures on Nicaraguan emigration patterns
(IOM 2013), which state that a large part (50%) of Nicaraguan emigrants
residing in El Salvador originate from the department of Chinandega, where
Cuatro Santos is situated, and that almost 14% of all Nicaraguans in Costa Rica
originate from the León area (compared to 10% from Chinandega department,
of which the majority probably come from the regional capital, Chinandega).
According to IOM (2013), about 8% of Nicaraguans residing in the US
originate from the two settings of this study, respectively (regarding
Chinandega, most probably come from the regional capital, rather than the
rural parts, e.g. Cuatro Santos).
In the survey we also asked about the immigration status of these emigrated
relatives. As presented in Table 9, the majority (80%) of the respondents
stated that they had emigrated relatives with legal immigration status
(denoted “with legal documents” in the table). However, over a third (36%)
had family members abroad who were undocumented. This can be related to
previous studies stating that a large share of Nicaraguan migrants in the US,
for example, are undocumented (Massey & Sana 2003; Donato et al. 2005).
Table 9: Immigration status of emigrated relatives
Family members abroad
All respondents
León
Cuatro Santos
67,6 %
71,7 %
65,8 %
%a
- with legal documents
79,6 %
91,8
- undocumented
36,2 %
18,2 % a
74,1 % a
44,3 % a
Notes: Based on Questions 6, 7 & 20, Survey 2008. Weighted percentages. p<o.001.
a
There was, furthermore, a contrast between the two study settings regarding
this aspect. In León, a higher share had family members with legal status,
whereas in Cuatro Santos it was more common to have undocumented
migrants in the family. This might be related to socio-economic factors; for
example, that León-migrants due to higher incomes have a greater possibility
to acquire passports and visas. But it might also be due to existing migration
networks; for example, that León migrants have a longer history of migrating
to the US, and therefore may be more prone to be granted temporary or
permanent residence. It may also be related to the migrant destinations, and
regulations concerning immigration. As mentioned, more respondents in
Cuatro Santos had relatives in Honduras and El Salvador, and it is generally
much easier to move to these countries without legal documents due to their
uncontrolled borders (however, a valid identification card is in fact required,
and there is a time restriction of six months on one’s stay; also, a permit is
required in order to work; Alba & Castillo 2012). Thus, if the border is crossed
134
without the necessary ID card136, a person stays longer than six months, or
work is undertaken without a permit, a person can be regarded as
“undocumented”.
The survey also included questions about where the respondent was born and
whether he/she had moved on any occasion (Questions 1-2), thus covering the
respondent’s personal migration history. The results showed that the majority
(83%) of the survey respondents were born in the same municipality where
they resided at the time of the survey, and that 13% were born in another
municipality. Only 4% were born further away (in another department or
abroad) (Figure 8).
3%
1%
Within the
municipality
13%
In another
municipality
In another
department
83%
In another country
Figure 8: Place of birth. Weighted percentages.
Based on Question 1, Survey 2008.
Even though the majority presently lived where they were born, almost half of
the respondents (47%) had moved at some point in life (Table 10) (many of
the migrants had thus returned to their birthplace). Most had moved locally,
i.e. within the same municipality or to/from another municipality (33%), and
only smaller shares had moved regionally, i.e. to/from another department
(8%), or internationally (7%).
Table 10: Migration history
All repondents
León
Cuatro Santos
52.7%
40.9% a
57.3% a
Local migrant
32.5%
43.9% a
28.1% a
Regional migrant
7.9%
11.3% d
6.6% d
6.8%
3.8% c
8.0% c
Non-mover
International migrant
Notes: Based on Question 2, Survey 2008. Weighted percentages. a p<o.001, b p<o.o1,
p<o.o5, d p<0.1.
c
136 Many Nicaraguans, especially among the socio-economically disadvantaged groups, lack a birth certificate
and/or ID card.
135
Thus, even though the majority of the moves were of a local character, 14%
had in fact migrated longer distances. These findings are similar to, or
somewhat lower than, other statistical reports of migration in Nicaragua – for
example, the UNDP (2009) states that 13 % of the Nicaraguan population are
so-called lifetime internal migrants, and IOM (2013) estimates that 10-13% of
the Nicaraguan population are international migrants. The differences
between our study findings and the national figures can perhaps be explained
by the observed variances between two study settings regarding the
respondents’ migration histories. In León, the number of those who had made
internal migrations (local or regional) was significantly higher than in Cuatro
Santos, which was expected since León has historically received more inmigrants and because residential mobility (i.e. moves within the same
municipality, included in the category “Local migrant” in the table) is usually
higher in urban settings. In contrast, Cuatro Santos showed significantly
higher numbers of respondents with experiences of international moves. This
may be interpreted as international migrants originating from Cuatro Santos
more often returning to the birthplace.
In the survey, we also asked the respondents if they had thought of moving
somewhere else137, and if so, where (Questions 3-4). The results showed that
only about one of ten (11%) respondents had considered moving at the time of
the survey (Figure 9). In León, the share of those who expressed thoughts of
moving was significantly higher – over a fifth (21%) of the respondents,
compared to 8% in Cuatro Santos138. This was not unexpected, as León has a
higher share of migrants compared to Cuatro Santos (see Table 10), which
furthermore might be explained by the higher socio-economic status in the
area affecting the propensity to migrate.
30
20
21,1
11,4
7,7
10
0
All respondents
León
Cuatro Santos
Figure 9: Expressed intentions to move. Weighted percentages.
Based on Question 3, Survey 2008.
Of those who said they were thinking of moving, almost 60% wanted to move
abroad. The stated motives behind the intended moves will be presented in
the next section of the chapter (“Motivations for moving and staying”).
137 Question 3 read: “Have you thought about moving to another place?” (see Survey 2008, Appendix).
138 p>0.001.
136
Summarizing comment
The survey study thus showed that about half of the respondents had moved
at some point in life. The majority had moved locally, but 14% had made
longer (regional or international) migrations. Furthermore, both translocal
and transnational migration networks were common, according to the survey
study. Costa Rica and the US were the two most important destinations for the
emigrated family members; however, Honduras and El Salvador were also
important destination countries in Cuatro Santos. The majority stated that
their emigrated relatives had legal immigration status; however, a large share
also had undocumented emigrated family members.
The qualitative study included individuals with diverse migration experiences
(of having migrated personally, of leaving family members behind, and/or of
being a family member of a migrant, i.e. a left behind). The interviews showed
that migration categories were often blurred (i.e. that the same person could
have several different experiences), and that migration and health were often
connected in complex ways during the life course. A central conclusion of this
study is therefore that the categorizing of people – into, for example
“migrants” and “left-behinds”, “healthy” or “sick” – is not easily done, and
must be considered in studies on migration-health relations. Like the survey
respondents, most of the interviewees had family members who lived in other
places. However, the extent of these migration/translocal networks naturally
varied greatly. Similar to the findings of the survey study, many of the
interviewees had relatives in the US, Costa Rica, and other Central American
countries.
As seen in the qualitative and quantitative material, migration was common
in the study setting, even though not everyone had personal experience of
migration. Migrant networks were nevertheless salient features in the study
setting, although they varied in extent and character. In relation to the
research on migration dynamics, it is clear that the patterns of Nicaraguan
migrations have unfolded transnational dynamics that may contribute to
further international migration. The interviews showed that migration
networks sometimes played a crucial role in the decision to migrate. For
example, Joanna moved to Guatemala because her husband had many years
of experience working there, and she also had a brother and numerous friends
there. Juliano had moved to the US because he was granted residency through
his father, who had received it through his own mother. Marta moved to León
because she had a cousin there with whom she and her children could stay.
And, Orlando moved to León as a child because his aunt lived there. The role
of migration networks in the migration decision process will be discussed
137
further in the next section, which pays attention to the motivations for
migration, staying and returning that were expressed in the study.
Motivations for moving and staying
This section deals with the various motives for migration and non-migration
expressed by the study participants. The decision to move or stay, and where
to go, is based on a variety of considerations regarding one’s current life
situation in the place one lives, and expectations about the possible future
outcome in alternative destinations. A substantial body of literature within
migration research deals with the issue of the individual and his/her
motivation for migration (De Jong & Gardner 1981; for overviews see
Robinson 1996; Skeldon 1990). As discussed and demonstrated earlier,
migrants’ decision-making does not take place once-and-for-all or in isolation.
Halfacree and Boyle (1993), arguing for a biographical approach, suggest the
need to move away from seeing migration as a discrete act towards seeing it
as an “action in time”. While stated motives and intentions provide important
insight into how people rationalize and make sense of their behaviour, the
underlying causes of migration must be sought in historical socio-structural
processes, as I argue in Chapter 4. However, if put into context in relation to
qualitative data, stated intentions and motives expressed by a large number of
migrants in surveys at a specific point in time provide important knowledge
that can give us clues as to how and why migration does or does not take place.
As shown here, in the study setting migration can to a high degree be
interpreted as being embedded in the strategies for making a living; it is thus
practised within the realms of mobile livelihoods. However, it was often more
than economic issues that were integral in the decision to move or stay, for
example social and health concerns. Health issues could furthermore
sometimes be of crucial importance for migration decisions. In this section,
results from the survey study will first be presented, and thereafter the
qualitative results.
Survey results: stated motives behind intended moves
As previously mentioned, 11% of the respondents replied affirmatively to the
question of whether they were thinking of moving to another place (see Figure
9, p. 136). As a follow-up question, the respondents were also asked: “Why
have you thought about moving there?” (Question 5). The results showed that
over two-thirds (68%) expressed economic motives (i.e. unemployment, poor
income, for work, for better work) (Figure 10, next page). More than a third
138
(35%) of the respondents mentioned social reasons, and some also mentioned
education (5%) and health (2%) as motivational factors.
Other
(has intentions to move=11.4%)
9,2
Health
2
Education
4,8
Social
34,8
Economic
67,8
0
20
40
60
80
Figure 10: Stated motives behind intentions to move. Weighted percentages.
Based on Question 5, Survey 2008.
Hence, even though economic motives for migration dominated, other
reasons were also stated. These findings should be seen in light of the fact that
migration motives are often complex and include many different reasons, and
that motives for intended migration may differ from motives behind actual
moves (e.g. De Jong & Gardner 1981). Moreover, intentions often change over
time; for example, economic motivations may dominate during certain
periods and under certain conditions, while in other times social reasons can
be more common. While income and economic conditions may not always be
the prime reason for moving, the expected economic outcome of moving
almost always influences the decision in some way. Furthermore, economic
motives are often more prominent in low-income countries, while today noneconomic motives are more common in high-income settings. Moreover,
while individuals may not consider social aspects to be the main motive
behind a move, social relations can affect the decision-making process in
many ways (e.g. the attraction of relatives in distant locations, and the
constraints of local ties). Similarly, good health may be a prerequisite for
moving, but it is rarely a stated motive for moving or staying. In addition,
individuals’ decisions are often embedded in a household context and are
rarely the outcome of a sole decision-maker. The individual’s stated motive
will therefore often only give an imprecise picture of the negotiations in a
family that ultimately result in a migration decision. (Also, bear in mind that
the findings are based on a small number of observations, since only 11% of
the respondents had actually thought of moving).
A significantly higher share in Cuatro Santos than in León mentioned social
reasons behind their intention to migrate (50% compared to 21% in León)139.
Social reasons can include moving closer to family members living in other
places, or can be related to household formation and dissolution. They can
139 p>0.05.
139
also be related to a wish to move away from a social situation that is not
satisfying, for example conservative social norms (which may restrict people’s,
e.g. women’s, possibilities to make the most of life), or to a desire to see new
places (Stjernström 1998; Boyle, Halfacree & Robinson 1998). Social reasons
for migration were also highlighted in the in-depth interviews. For example,
Ana left her home “in the mountains” because she had been subject to sexual
abuse within the family and no longer felt like part of the family. Mercedes
moved away from her village because, as the only daughter in the family, she
had to work hard with household chores as well as in agriculture, and
therefore preferred to look for better life circumstances in the city. And, both
Mercedes and her husband Orlando believed that the town was a much better
place to live than rural areas, because there was more “enlightenment” and
“development” there (thus highlighting what is denominated the lure of the
city). The qualitative data thus provided a contextualized understanding of the
survey findings concerning social reasons for migration, and will be discussed
further in the coming pages.
Qualitative results: the troubles making a living and striving for
a better life
Like in the survey, many interviewees accentuated economic motives for
moving or staying. Yet, the interviews provided a more diverse and complex
pattern than this, in which different motives for the acts of moving, staying
and returning were often blurred. Thus, even though economic motives were
often emphasized, health concerns, for example, could be embedded within
these motivations. A general concern of the interviewees was nevertheless the
struggle to make a living under the harsh Nicaraguan living conditions. Many
talked about how life in Nicaragua was hard (la vida es dura 140), due to things
like poverty, unemployment and low incomes. Many also talked about the
importance of support networks for getting by (or how the lack of them made
migration a necessity). Most of the interviewees also expressed how they
aspired to “move forward” (salir/seguir adelante) – for a better life for
themselves, and for their children in the future. This section first presents
different aspects of the troubles of making a living, which along with striving
for a better future was a principle motive for migration.
140 Words in italics in the text are original phrasings in Spanish, used by the interviewees. Underscored words
in the quotations are words the interviewee emphasized as he/she spoke. Questions starting with “C:”
surrounded by << … >> were follow-up questions I posed during the interview.
140
Poverty, crisis, and the need for support
Several interviewees emphasized that the widespread poverty in Nicaragua
was a motivation for migration. The importance of support from others within
the social network, due to the difficult living conditions and in times of crisis,
was also highlighted by many – for example Gloria.
Gloria, who was 60 years old, was born and raised in Cuatro Santos, where
she still lived with her husband and their two youngest children. In our
interview Gloria talked about the difficult living conditions in the area,
particularly the lack of job opportunities, which made it hard to make a living.
The family worked as farmers – cultivating corn, fruit and vegetables. They
sold some of their harvest at the local market, and used this income to buy
products they did not grow. Because of the economic situation, Gloria’s three
eldest sons had left Cuatro Santos. One had been living in the southern parts
of Nicaragua, where he worked in a café, for two years. The two others had
gone abroad three to four months before our interview; one to El Salvador and
one to Costa Rica. The son in El Salvador had a wife and two children in Cuatro
Santos whom he supported.
Gloria:
“The situation here is quite hard, so they [her sons] have been working there
[in El Salvador and Costa Rica]. […] They haven’t gone abroad for vice [para
vicio], but to help their households economically. […] The majority goes away
here, because there are no jobs. There aren’t any. You know, this is a country
that… We don’t have anything to live on. There are no jobs…no fixed jobs,
right, there aren’t any. […] Here, we live mostly on what we sow…corn… Here
in Nicaragua, we live mostly on tortillas.”
In the quote Gloria says that her sons, and many others, have all moved
because of the difficult living conditions in the area. She also underscores that
her sons are not “bad”, but are rather good people trying to improve their
situation. Through this she thus relates to, and talks back to (resists), the
discourse of Nicaraguan migrants as “threatening others” (see SandovalGarcía 2004). The issue of the “othering” of migrants will be discussed more
in Chapter 6.
Furthermore, Gloria said she did not receive much help from neighbours or
friends, but mostly from her sons who lived in distant places. She had
nevertheless received a great deal of help from a local development project, of
which she spoke very highly. Gloria’s narrative highlights the difficult living
conditions many rural Nicaraguans endure, as well as the importance of
development aid. (Gloria might, however, have been influenced during the
interview by the presence of a man who had accompanied us, who was closely
involved in the local development project, as mentioned in Chapter 3). Thanks
141
to the development project, Gloria and her family now had access to clean
drinking water (which made them much healthier), and several of her children
had received scholarships and professional training. Her oldest daughter lived
in León where she was studying to become a teacher on a scholarship from the
project, and her son in Costa Rica was working as a carpenter, a trade he had
learnt thanks to classes provided by the project. Gloria and her husband had
also received agricultural support, so that their harvest and revenues from
selling it had increased, which had slightly improved their economic situation.
Gloria:
“[T]his project that they [the project leaders] have brought us…it’s a great
benefit [un gran logro] that we’ve received, right. In our case, we grow a lot of
papaya. You know papaya, right? Before the project we had so much that it
spoiled, we couldn’t use it all. But now…we can sell it. It’s a great benefit that
we’ve received. […] Regarding the education also, right. You know, here we
live hand to mouth [aquí vive para comer], even if they [the children] want to
study, we can’t…”
Even though Gloria and her family had received help in different ways, four of
her sons had nevertheless felt it necessary to move away in order to improve
the family’s economic situation. Migration was thus embedded in the
household’s strategy for making a living. Gloria, who had never been outside
Cuatro Santos, where she was born and raised, herself had no thoughts of
moving, however. When I asked if she had any hopes for the future, she
seemed to put a great deal of faith in the local development project to improve
the living conditions in the area and for her family. She emphasizes that
without the support of development co-operation, she and her family would
go back to being poor farmers, without possibilities to change their living
conditions.
Gloria:
“My hope for the future, right, is that other countries continue their support
to [the project leaders] so they can continue to help us. But, if the other
countries withdraw their support, we’ll live as before. Our children will only
learn to make tortillas and use the machete [nuestros hijos aprendiendo solo
a la tortilla y al machete campesín].”
Another interviewee, Fernando, also talked about the poverty that made it
difficult to make a living. Fernando was 55 years old and lived in an urban
centre in Cuatro Santos, also the place where he was born and raised. At the
time of the interview he was living alone with his two youngest sons; his wife
had been working in Spain for seven months, and three of their grown children
had moved away from home to other localities in Nicaragua. In his youth
Fernando had lived for many years in Managua, which is where his mother
and siblings still lived. At the time of our interview he was working as a
member of the town council, as well as a farmer. For many years prior to the
142
interview, Fernando and his wife had run a small shop in their home where
they sold crops they grew in the surrounding hills. Unfortunately, they had
been forced to close the shop because sales had gone down, and they
subsequently acquired a large debt. Due to troubles making a living, Fernando
had gone to the US to look for work; thanks to his political position he had
received a visa, which he overstayed. However, he was forced to return six
months later for health reasons, and his wife subsequently left for Spain in an
attempt to solve their economic problems.
Fernando:
“The poverty you see around here… in almost all of Nicaragua you see poverty.
Here we survive, survive, on corn… The economic problems are such a burden,
you don’t see a way out, so… […] You see people leave…to El Salvador, to Costa
Rica, Spain, the US, a few to Guatemala, to Panama… […] We had a
debt…and…we couldn’t pay it back… I was in the US for a time, but not for
long…it didn’t go well for me, so I returned. So…well, she [his wife] had to
emigrate. […] It was an alternative we had for getting out of this agony [atroz],
it was all we wanted. […] Now we’re getting out of these problems.”
Fernando thus portrayed Nicaragua as a poor country, and migration as a way
for people to escape poverty and economic difficulty. Through his narrative,
mobility can thus be seen as being embedded within people’s attempts to
make a living in the rural area where he lived, as well as in Nicaragua at large.
In relation to my question of whether people in his community helped each
other, Fernando answered that the community was very united (aqui
convivímos) and that people supported each other often, in different ways.
Even though he said that an air of co-existence and supportive social relations
existed in the community, Fernando and his wife had seen no other option
than to go abroad in order to solve their economic situation. Fernando’s story
also shows how health (ill-health) can be a motive for returning home.
Moreover, Fernando’s story is interesting as it highlights the “feminization” of
migration in the case of Nicaragua (i.e. that an increasing share of Nicaraguan
emigrants are women; see Chapter 4) through which more men are left
behind, with the result that more men assume responsibility for the household
(e.g. child-raising). This phenomenon contradicts the prevailing gender
structure141 and the general care regime in Nicaragua, according to which
141 The dominant Latin American, and Nicaraguan, gender structure is generally assumed to build on the two
opposing ideals of masculinity and femininity – machismo and marianismo. Machismo “has historically been
viewed as a set of hegemonic masculinities that legitimizes patriarchy” (Salazar Torres et al. 2012: 2), and
involves attitudes and behaviours that “dictate how men interact with women and with other men” (ibid.).
Machismo furthermore emphasizes that men are “sexually-driven and in need of exercising domination”
(Salazar Torres 2011: vii). Marianismo “idealizes the figure of the Virgin Mary as a model of chastity, submission
and sacrifice for women” (Salazar Torres 2011: vii), and emphasizes the importance of virginity and
motherhood. Hence, it is “a form of emphasized femininity that reinforces machismo” (Salazar Torres et al.
2012: 2). Based on the ideals of machismo and marianismo, “real” men are believed to be tough, violent,
domineering womanizers (since men are believed to be superior to women), and “real” women are thought to
be docile and to comply with men’s patriarchal privileges (Salazar Torres et al. 2012; see also Lancaster 1992).
Gender norms are not static, however, and can be changed in relation to social processes (cf. Connell 2009).
143
social reproduction is usually the woman’s “task” (Martínez Franzoni &
Voorend 2011). The changes in family relations due to migration will be
further discussed in Chapter 7.
Gloria and Fernando’s narratives thus show how the difficult living conditions
and vulnerable livelihoods in rural areas in Nicaragua necessitate migration
in order to make a living. This illustrates the “structure of vulnerability”
(Wolkowitz 2006; with reference to Nichol 1997) that exists globally, due to
insecure and difficult working conditions. As mentioned in Chapter 2,
vulnerability can refer to many things, but at its core lies people’s exposure to
shocks or strains, and experiences of suffering (Pendall et al. 2012).
Vulnerability is said to be a more common trait today, as the social world is
highly characterized by uncertainty and as social and political institutions are
often unable to respond to social changes and provide for citizens (so-called
“precariousness of institutions”; Wolkowitz 2006). In the case of Nicaragua,
it can perhaps be argued that the population also has been in a vulnerable
situation in previous times, in relation to colonization, dictatorship, civil wars,
debt crisis, structural adjustments, and vast socio-economic differences in
society, particularly affecting rural areas, women, and the indigenous
population in the Eastern parts of the country. Nicaraguan socio-economic
transformations have thus always made some groups vulnerable; yet, in
connection to the “globalized” labour market and the economic crisis that
began in the 1990s, another form of insecurity and vulnerability has possibly
emerged because of the harsh living conditions, as explained in Chapter 4.
The interview with Rosa, whose migration biography was presented in more
detail at the beginning of the chapter, also highlights people’s vulnerability in
Nicaragua, but in the face of the unpredictable nature conditions there. It also
shows the importance of support networks in relation to this vulnerability. As
mentioned, Rosa’s husband died in Hurricane Mitch, which made Rosa move
with her children to an area where humanitarian aid was provided. She also
received help during this time from her late husband’s family, and from a
younger brother. The help Rosa and her children received after the disaster
was essential to their survival. After two difficult years in the provisional
settlement, Rosa finally received a plot of land and construction material to
build a house.
Rosa:
“I decided to go where people were getting things, where they were helping
people. They helped me a lot, they gave me clothes, food and things like that.
They gave us some land where we could set up a little house [chambita] in
Nevertheless, although women’s rights in Nicaragua have been promoted since the revolution, and some
improvements have taken place, patriarchy and machismo still continue to be prominent features of Nicaraguan
society (Salazar Torres 2011).
144
plastic. We lived like that for about six months. […] An organization, “Save the
Children”, gave us food. They helped us a lot, with clothes, milk… And, I still
had my sister-in-law, she helped me with the children, at first, she gave me
money. And, then they [the NGO] gave us a small house, but we had to work
for two months. They gave us the building material but they didn’t give us the
labour force to build the house. So they hired workers, carpenters, foremen,
so we, the owners, served as the labour force. So, we worked and built the
house. That was about two years after the hurricane [Hurricane Mitch], I’m
not lying. We lived in the plastic house for a year, enduring sun, wind, dust,
and everything. And after that we started building houses, and it took nine
months before we got our house.”
Rosa’s story thus highlights the vulnerability many people face in relation to
environmental disasters, and the crucial need for humanitarian support and
social networks in times of crisis. It also shows the strength of people in such
situations, and how migration is used as a strategy for survival. Importantly,
it also demonstrates how, in the absence of state and public institutional
support, NGOs and private actors have stepped in and assumed
responsibilities that should be the priorities of the state. This can be explained
both by the downsized public sector (due to structural adjustment policies),
and by the Alemán administration’s corrupt behaviour and incompetence in
handling the national disaster Hurricane Mitch proved to be (see Chapter 4).
Upon my question whether Rosa presently received any help from others, for
example from relatives, friends or neighbours, in supporting her children who
were living with their grandmother, Rosa said that she had to manage on her
own.
Rosa:
“Well… For example, if one of my children were to get sick no one would help
me, I have to solve my own problems. I have brothers and sisters, but they’re
married. I’m the only one who has to go away like this to work. […] No one
helps me… My mother’s very poor, she helps me raise them and take care of
them, but economically no one helps, I have to do it. My sister takes them to
see the doctor, but I have to pay for it. They help me in this way. […]I’m the
only one who works outside the farm [la finca]”. <<C: And, no one else in your
family has gone abroad?>> “No, no. Only me. My needs made me go abroad
[Mis necesidades me han ido salir]”. <<C: Because you’re alone?>> “Yes,
because I’m alone, I don’t have anyone who helps me.”
Rosa thus reasoned that migration was a necessity for her, due to the little help
she received from those around her. Even though she had close relatives (a
brother and a cousin) in Costa Rica, they were occupied with supporting their
own families. Rosa’s story thus shows that, in relation to socio-economic
disadvantage, the family support network may not be sufficiently resourceful
to provide for all its members. Migration then becomes a strategy for coping
with a lack of social support.
145
People may face vulnerabilities in urban contexts in Nicaragua as well, and
therefore have a need for support. The interview with Mercedes and Orlando
offered important insight concerning extreme poverty, and the role of social
networks and international aid in peoples’ possibilities to make a living – and
surviving – in the Nicaraguan context. Therefore I will now delineate a bit
longer on their story.
At the time of the interview Mercedes, who was 34 years old, lived in one of
the poorer sections of León with her husband Orlando (47 years) and their six
children, aged between 6 and 17. Mercedes and Orlando were born in two
small neighbouring villages to the north of León. Both came from poor,
hardworking families of farmers (familias pobres y luchadoras). At a young
age Orlando moved to León to live with his aunt, upon the separation of his
parents. Mercedes, who had been raised by her aunt because of her mother’s
epilepsy, moved away at the age of 14 to look for work, since she did not enjoy
the rural lifestyle.
Mercedes:
“I was born in […], a municipality in Chinandega. When I was three months
old my mother moved to […], a village close to the Malpaisillo highway. It was
there I stayed, grew up. But, when I was 14 years old I left home for León.
Because my parents were very poor [muy pobrecita], life in the village was
very hard [muy dura], because sometimes there are few jobs. For me…living
there was very hard for me, because I was the only daughter, and my mother
is a farmer, so since I was a little girl I went out to work in the field… And, I
never liked that, because it’s a very tough job [un trabajo muy pesado]… […]
Well, so then, I came to the city to work as a maid [domestica]. I worked in
Managua, I worked in León, but I wanted my life to change. I didn’t want to
work as a maid because some employers abused me…in terms of money, that
they didn’t pay me, there was physical maltreatment…this was hard for me.”
Thus, due to prevailing gender roles, Mercedes had a tough childhood in the
countryside including a great deal of hard work. She therefore decided to
migrate, and as a young, female migrant, her most accessible opportunity was
to find work as a maid. However, in this work she suffered from both economic
and physical maltreatment. Therefore, when she met Orlando she was
relieved, and swiftly moved in with him and started working in his artisan
workshop. Approximately three years before our talk Orlando’s sister, who
owned the house they were living in, died, and since she left behind no official
documents of ownership of the house, another family (with more resources
and power) took possession of the property. Mercedes, Orlando and their
children were thrown out on the street and left with nothing. They spent the
next two weeks outdoors, in a park close to their former home.
Mercedes:
“My sister-in-law died, so when she died…there were other people who seized
the land where the house was, since my sister-in-law didn’t leave papers, so
146
these people had more money, they paid, they bribed the lawyers, the judges,
and so they threw us out on the street. […] We stayed in a park, just half a
block away from our house, for 15 days, evicted, without home, without food,
without work, with nothing, completely destroyed, crushed…”
In this devastating situation, Mercedes and Orlando had very few people to
turn to for help. With the death of Orlando’s aunt they now had no family
members in León, and their relatives who lived at their birthplaces, like
Mercedes’ mother, were too poor to provide any help. The only ones to offer
help were their old neighbours, with whom they had become close friends over
the years. For instance, they collected money as a gift to the family, and also
bought them clothes and household items.
Mercedes:
“Here in León we don’t have any family, here we only have friends. […] Just
imagine, when we were evicted, everyone in the neighbourhood [el barrio]
there, they all stepped up, they all helped us, they weren’t okay with our being
kicked out… They all stepped up, everyone in the community [el pueblo],
everyone in the neighbourhood, to give us help.”
Mercedes and Orlando’s social network was thus very important in this
situation. And thanks to the town council, shortly after their eviction Mercedes
and her family were given a plot of land; albeit in another, more deprived, part
of town (where they were thus living at the time of the interview). Mercedes
and Orlando consequently took the few things they still possessed to their new
settlement, and gathered building material to construct a small house, in
which they also set up the artisan workshop. However, Mercedes said, it was
not easy for the family to move to a new neighbourhood. They were
“strangers”, so no one was very friendly in the beginning. For example, even
though Mercedes and Orlando were in a disastrous situation, and had no
possibility to work and hence no income, they were not given credit at the local
shop to buy food for their children. It also took time before the neighbours
started greeting them on the street. At the time of the interview, the social
situation had improved a bit (the neighbours had at least started to say hello);
however, they still felt they did not know the neighbours well enough to ask
for favours or help. Luckily, the family had received a great deal of support
from an NGO (Non-Governmental Organization) working in the area,
providing help to families, and especially children, who were in need. Thanks
to “the project”, as Mercedes called it, her children could go to school, and they
received other types of help as well, such as medicines or money when the
children were sick.
Mercedes:
“So, they [the NGO] offered us their help, so that the children would be able
to go to school; because back then I couldn’t send them to school, I didn’t have
any money, I didn’t have a job, I didn’t have anything, so they’ve helped me a
lot so that my kids can go to school. They’ve helped us for three years. They
147
help my children with their school stuff, they help me with shoes, uniforms…
It’s a great benefit [ganancia] and a great help to us.”
Mercedes had also had the opportunity to enter adult education thanks to the
project, and it had also helped her get a job at a hospital, where she worked in
the laundry section for eight months. After a tough year of working during the
day and studying in adult education at night, she managed to complete the
sixth grade. She was then given the opportunity to enter a training programme
(capacitatión) in beauty (manicure and pedicure), which was something she
had been wanting to do ever since she was a child (however, during her
childhood she had only managed to complete the fifth grade, due to the lack
of educational possibilities and her family’s poverty). Some time before our
interview, Mercedes had started to attend clients in their homes, and made a
bit of money from this work. Her income was a great contribution for the
family, since Orlando’s income from the handicraft business had substantially
decreased due to the move and the loss of clientele it caused. Some of their
old, regular clients did not know where they had moved, and others did not
bother to make the trip across town. Besides “leaning” on the NGO for
support, Mercedes often asked her clients – who had become more like friends
– for help when she was in need. Nevertheless, a great concern for Mercedes
and Orlando was that their house did not have a proper door, which meant
that their belongings were unprotected whenever they were not there, and also
made them feel very unsafe. In the quote below she describes that,
notwithstanding the help she has received over the years, she still suffers from
extreme poverty, as she did in her childhood.
Mercedes:
“I’ve lived through two stages… I was born in extreme poverty, so that
sometimes we didn’t even have enough to eat…a very hard difficulty, and what
I’m going through right now, with my children, it’s a misfortune, if I might say
so, an eviction, and I’m also living in extreme poverty…”
When I met Mercedes and Orlando a year after our first talk, even though they
were working as before they were in an even more difficult economic situation
than when we had first met, primarily because the organization who helped
them with the children’s schooling had not provided them with clothes that
year, and because of increasing food prices. Despite the difficult economic
situation, their living conditions had become somewhat better. The house had
been improved (they had packed the ceiling and the walls with plastic to avoid
leakage), the garden had been expanded (they had planted fruit plants), and
they had better drainage and water supply (they had built an outdoor shower,
a toilet and a wash stand). All this had made a significant difference in their
life, they said. Moreover, Orlando had gathered wood to build a new, proper
door, but had not yet had the time to do the work. Luckily they had managed
148
to put a lock on the old door, which made them feel somewhat better. But even
though these changes were great improvements they wanted a proper house,
and were seeking help from different organizations to build one. In relation to
this, Orlando said: “Nicaragua lives on the support we get from foreign
donors”. Still, Mercedes and Orlando had a very hard time making ends meet,
and were extremely worried (preoccupada) about their bad economic
situation. They were trying to find solutions, and turned to friends for help.
Mercedes had also tried to expand her business, through advertisements. She
had also thought about going abroad, perhaps to work as a maid, in order to
make more money (but this never took place, as I learnt in 2013).
Mercedes and Orlando’s story illustrates well the vulnerability faced in a
situation of extreme poverty, and that migration is ever-present as an
alternative strategy for making a living. But, more importantly, their story
highlights the crucial role of social networks, and local and international
development co-operation, in getting by in the context of the study setting.
Family support networks, and other support networks (from, e.g., civil
society), are indeed particularly important in contexts of poverty, and there
are several studies that highlight this in relation to Nicaragua as well. For
example, Anna Johansson (1999: 133) writes that “[o]ne of the implications of
being poor is that you are dependent on the help of others to survive”, and that
the pattern of help exchange in Nicaragua (or in the Managuan
neighbourhood she studied) was one of reciprocity, mutual giving and taking
(see also Mulinari 1995; and Lancaster 1992). Furthermore, in her study on
child work in Managua, Aida Aragão-Lagergren (1997; with reference to Renzi
1996) mentions that a common strategy for poor Nicaraguan households is to
rely on economic support from outside the household (so-called
contributions), for example from relatives, state institutions and NGOs.
Similarly, Martínez Franzoni and Voorend (2011) state that families play a key
role in the survival strategies of the Nicaraguan population and, furthermore,
that these family networks rely heavily on women (mothers, daughters, other
female family members). Therefore, they argue that Nicaragua is more similar
to a “familistic” welfare regime and is consequently different in many ways
from “traditional” welfare regimes, which often build on the idea of the
heterosexual couple and the nuclear family. In this context, family support
networks then become “a central resource in the process of social
reproduction of individuals and their families: they allow access to other
resources (education, work, income, health), [and] they play a decisive role in
carrying out certain daily activities (care of children, domestic work, care for
the sick…)” (Ariza & Oliveira, 2004: 26; quoted in Martínez Franzoni &
Voorend, 2011: 996). The importance of social networks and the exchange of
help will be further illuminated later in the chapter.
149
Unemployment and low incomes
Other interviewees highlighted the malfunctioning Nicaraguan labour market
as influencing people’s decisions to migrate (e.g. unemployment, lack of
steady jobs, and low incomes). According to national figures, presented in
Chapter 4, the official unemployment rate in Nicaragua is about 10%, yet more
than 50% of the Nicaraguan population state that they are underemployed.
About two-thirds of the population works in the informal sector, because of a
lack of formal employment (UNDP 2013; Pozzoli & Ranzani 2009). Due to low
incomes,142 many have a difficult time making ends meet (in 2006, 70% could
not afford to buy what they needed to live on, according to Walker & Wade
2011, with reference to CENIDH 2007). These issues were highlighted in the
interviews with Cesar, Juliano, Carmen and Joanna.
Cesar, a 31-year-old Leónese living in León with his wife and their two
children, talked in our interview about the difficulties of finding a job in
Nicaragua – even if you have an education – and the troubles making ends
meet due to the low salaries. After graduating from secondary school with a
diploma in computer science Cesar started looking for work, but never
managed to get a qualified position. The jobs he could get were low-paid, and
even combined with what his wife earned through her work in an assembly
factory (C$2,000 a month) this was not enough to sustain them. The best job
alternative for Cesar in Nicaragua was to drive a taxi, which was what he was
doing when our interview took place.
Cesar:
“Here in Nicaragua, there are hardly any jobs. No one I studied with in school
works with what he or she studied. You might find one [a job], but the salary’s
very low. Here they only pay you C$1,500-1,600 [US$57] per month, and
that’s nothing here. […] At one time, I worked as a private chauffeur for a
month […] and I only got C$1,200. […] No way, I said. With 1,200 a month,
my family would die of hunger [se muere de hambre]… I can’t make ends meet
[no me sale la cuenta]. So, I learnt to drive, and started driving a taxi. Then I
could sometimes make C$1,000 in three or four days…”
Due to an unfortunate accident with the taxi, Cesar was forced to find a new
job in order to cover the expenses as well as sustain his family. When such an
occasion did not present itself in Nicaragua, he saw no other alternative than
to go abroad. Cesar had a large international migration network, which was a
strong motivational factor for him to migrate. He had relatives living in Costa
Rica (some of whom had been there 30-40 years), Honduras, Guatemala, the
US and Spain. Furthermore, his mother had lived abroad (in Honduras and
142 In 2009 the average annual income in Nicaragua was 13,700 córdobas (C$), equalling US$527 (C$1,000
amounted to US$38, in 2014). There are vast differences between the highest and lowest incomes, however
(from C$28,000 to C$6,800) (INIDE 2011). See Chapter 4 for more details.
150
Costa Rica) during much of his childhood; she was the one who had initially
encouraged him to go to Costa Rica, when she heard he was about to get
married.
Cesar:
“When she [his mother] returned from Costa Rica I was about to get married.
But when she came she said, why are you going to get married? She didn’t
know the girl. So she said, I won’t spend all this money that I’ve brought with
me. Don’t worry, I said, I’m going to get married. And then she encouraged
me to go to Costa Rica, to have an adventure, to figure out what to do, and also
because of the economic conditions here.”
Cesar went through with his plans to marry, and eventually also went to Costa
Rica. Even though he had family members in Costa Rica whom he could
contact initially, he was not very pleased with the support they gave him. He
said that on the next trip he would prefer to go to a location where he had
friends instead. In the quote below, Cesar describes his moves from and to El
Salvador, Nicaragua and Costa Rica – a circular migration pattern connected
to the job opportunities that presented themselves. Migration was thus a
strategy for making a living for Cesar, when opportunities failed him in
Nicaragua.
Cesar:
“I had an accident and I had to pay all this money, so I had to leave Nicaragua
because no one would give me a job here. I went to El Salvador first; I stayed
there only six months, because I didn’t like the job. I worked in road
construction; I only made US$6 per day, and the rent was C$40 per month,
and I had to think about food and to send money to my family here in
Nicaragua. I didn’t make enough. I went back to Nicaragua; I worked for a
while with a carpenter, and that helped me be able to go to Costa Rica with my
mother. In Costa Rica I didn’t have a job for two months; I looked, looked,
until I found one with a salary of C$50.”
Cesar had plans to return to Costa Rica shortly after our interview, because he
saw migration as a solution for improving his living conditions in the long
term. At the time of the interview he was hiring the car he was driving and
working as a non-authorized taxi driver (pirateando). Cesar wanted to get a
licence (a taxi sign, una placa), and a car of his own, so he would be able to
work during the day and make more money, and avoid the risk of getting
caught by the police and having to pay heavy fines. However, the taxi sign was
very expensive, and so was the car. Cesar saw migration as the only way to
make enough money to allow him to realize his goals.
Cesar:
“My goal is to go to Costa Rica again, because here no one can support
themselves… Work is bad here, I mean it’s difficult to drive a taxi, sales are
low, and if one finds a job the salary’s very low. […] If I go to Costa Rica I can
work hard there, and then buy a taxi sign.”
151
Cesar said that on his next trip to Costa Rica he would like to go somewhere
close to the border of Nicaragua, so that it would be easier to visit his family
in León. (This trip was postponed, however, Cesar told me when I met him a
year later in 2008.) He furthermore said he did not want to go to Managua or
Chinandega, because of the high crime rates and dangers there. Upon being
asked how he saw his life in ten or 20 years, Cesar recounted that his main
goal in life was to get a big, nice house for the family, which his daughters
would inherit when he and his wife died. He also wanted to see his daughters
go through school and have a good life. He hoped his economic situation
would improve and that he could later run a small business of his own. And,
he also wished to start a savings account with the money he earned abroad, to
which both he and his wife would have access if one of them were to die. Cesar
put a great deal of trust in God to achieve these goals, but also in his own
power.
Cesar:
“I leave it to God… If I die, I die, but if he tells me to keep fighting until I reach
my goals, which are to have my own big house and to see my daughters get
educated and live well, so that they have a good future… […] I hope [ojála]
that God helps me and that I can overcome economically… […] I’ll see what to
do to come to the point where I want. One just has to stay strong, right? [Todo
es forzándose, no?]”
Cesar presents himself in the interview as a very strong individual who, in
order to cope with the economic troubles, fights hard and keeps the faith in
order to accomplish the goals he has in life. The aspects of stress, health and
coping are relevant to discuss in relation to Cesar’s narrative. Stress can be
defined as “any environmental, social, or internal demand which requires the
individual to readjust his/her usual behavior patterns” (Thoits 1995: 54). The
literature points out three major types of such demands, called stressors – life
events (e.g. divorce), chronic strains (e.g. poverty), and daily hassles (e.g.
traffic jams). Migration can, furthermore, be regarded as a stressful life event
(Helman 2007). Stressors in turn stimulate coping processes, which can be
defined as an individual’s “efforts to cope with the experienced behavioural
demands and with the emotional reactions that are usually evoked by them”
(Thoits 1995: 54; italics in original). Moreover, coping is enacted when the
individual appraises a situation as “personally significant and as taxing or
exceeding the individual’s resources for coping” (Folkman & Moskowitz 2004:
747) (see also Lazarus and Folkman 1984; Antonovsky 1979). Hence, coping
takes place when the individual makes the appraisal that something that is
relevant for him or her is, for example, harmed, lost or threatened, in a
situation that feels difficult to handle. Individuals’ capabilities to cope vary
depending on their access to coping resources; that is, the “social and personal
characteristics upon which people may draw when dealing with stressors”
152
(Thoits 1995: 59). Coping is thus a complex, multidimensional process that
takes into account both the individual (personality dispositions) and the social
environment (experienced or real demands, and resources). Some of the most
studied coping resources, according to Thoits (1995, 2010), are self-esteem,
social support, and sense of control or “mastery over life” (cf. Antonovsky’s
theory of Sense of Coherence, Antonovsky 1979). These resources are thus
commonly used in coping processes, and together form the basis of the
individual’s coping strategies, which thus can be defined as the “behavioural
and/or cognitive attempts to manage specific situational demands” (Thoits
1995: 60). Based on the coping strategies at hand, people may be more or less
suited to cope or readjust when facing demands, and this may also have effects
on their health (ibid.). According to Folkman and Moskowitz (2004), there is
evidence that religion also plays an important role in the stress process; for
example, through influencing the ways people appraise events, and the ways
people respond psychologically and physically to these events over the long
term (the authors refer to Park & Cohen 1993, and Seybold & Hill 2001). In
stressful situations, people may thus use religion “to help cope with the
immediate demands of stressful events, especially to help find the strength to
endure and to find purpose and meaning in circumstances that can challenge
the most fundamental beliefs” (ibid. p. 759).
Cesar’s narrative shows the strategies he employs in order to cope with his
stressful life situation. In order to find a way to support himself and his
children he works hard, both in Nicaragua and abroad, and tries to find a way
to improve the resources he has at hand, so that a better future can be achieved
for his children. He seems confident in himself, but also turns to religion to
find strength. He also shows a very strong commitment to his family, and care
for his children, which (similar to Fernando, who assumed the household
responsibilities in his wife’s absence), contradicts the prevailing view of the
“irresponsible” Nicaraguan machista/“Macho man” (see Footnote 141).
Juliano, a 24-year-old Leónese, had lived in Miami, USA, for four years. He
was married to Cindy, also a 24-year-old Leónese, and together they had a sixyear-old son. Even though Juliano had graduated from “high school”
(bachillerato), he did not feel he had much opportunity in Nicaragua due to
the poverty and unemployment, which he said even those with a higher
education suffered from. Juliano mentioned that his brother, for instance, had
not been able to get a qualified job despite his education. Juliano was very
grateful to have had the opportunity to go to the US, because of the difficult
living conditions in Nicaragua.
Juliano:
“Thank God they gave us the opportunity to be there [in the US]. I say thank
God, because this country’s very difficult…in the sense that there’s extreme
153
poverty here. […] Here, for example, there are a lot of people who are
engineers, doctors, lawyers, who you see working as carpenter’s assistants.
Well, who’ve never…never pursued their careers… If you don’t have friends,
know people… For this reason I see it [life in Nicaragua] as pretty difficult, for
the job opportunities… My older brother’s an engineer in husbandry; he
graduated a year ago, and has never worked within his career. He’s working
with my uncle, as a painter.”
Juliano and Cindy met at school, and had their child when they had just
started studying at the university. Consequently, both had to drop out in order
to find a way to support the family and care for their baby. Juliano worked as
a painter for a year before his emigration, but since he had no fixed job and
hence no stable income, he was making very little money. Even with the
income from Cindy’s job as a factory supervisor, they were making too little
for the family to live on. Due to their economic troubles they had not been able
to move into a house of their own, but instead had to continue living in their
respective family homes. In order for them to become independent and start
their family life in earnest, Juliano and Cindy decided it would be best for
Juliano to go to the US to work, since by this time he had received his US
residence permit, which he had received through his father who had become
a resident through his own mother, who had gone to the US in the late 1980s
after the Sandinista revolution. Juliano’s father and brother also lived in the
US. The quotes below are from the interviews with both spouses, who portray
the events similarly.
Cindy:
“After I graduated from high school (bachillere de quinto año), I entered the
university…and then I got pregnant. But, with the baby I couldn’t continue
studying because I had to look after him. And he [Juliano] was still here… He
lived with my sister-in-law for two years …because he worked, and then he
was unemployed… Because, you know, here in Nicaragua it’s difficult to find
a job, and even more when you don’t have your title [a profession],
but…sometimes even when you do it doesn’t help you anyway… We lived like
that for two years… His father had already submitted the application [for US
residency] and when he got it, he left… […] The baby was two years old when
he left.”
Juliano:
“We had to drop out of school and start working. […] Both of us worked for
about a year… And then, when I left, I said that she should stop working… […]
I said to her, there are more possibilities [if I go]. Well, I told her to stop
working, to take care of the baby, and to study a bit. Well, that she could
continue studying, that I could lend her the money and such.”
Juliano and Cindy were thus in a relatively good situation, with better
opportunities to improve their life than Cesar, for example, thanks to the
migration history of Juliano’s family and his possibility to live and work in the
US. He was very grateful to have the opportunity to be in the US, and this
154
positive emotion of thankfulness he expressed can be seen as an important
way of coping with the difficulties his mobile livelihood strategy entailed.
When I asked Juliano and Cindy about the future, they shared the same idea:
that Juliano would continue living and working in Miami, while waiting for
the residency application for Cindy and their son to be approved. Then, their
plan was to reunite in the US, stay there for a couple of years, work hard and
save money, before returning home to León, where hopefully by then they
would be able to get a house of their own. Their mutual dream can also be seen
as a way of coping with their life situation (more on this in Chapter 7).
The stories of Cesar as well as Juliano and Cindy highlight the problems of
unemployment and of finding jobs with decent pay in urban Nicaragua. These
problems also existed in rural contexts, however, as the stories of Carmen and
Joanna will show.
Carmen, who was 33 years old and lived in Cuatro Santos with her two
children at the home of her parents-in-law, talked about the difficulty making
a living in Nicaragua due to the lack of job opportunities. Carmen was born in
an adjacent community, into a poor farmer family. She had not gone to school
as a child, but had learnt to read and write when she was in her teens. Thirteen
years prior to our interview Carmen had met her husband, Gilberto, and
moved in with him and his parents. The family made their living mostly from
farming and keeping animals, and Carmen also made handicrafts of pine that
she sold at the local market and elsewhere. She had never been outside Cuatro
Santos, where she was born and raised, and had no thoughts of moving
anywhere else. Due to the family’s economic needs Carmen’s husband had
instead, a year before we met, gone to the US to look for work. Carmen said it
was more or less necessary for Gilberto to go abroad, for several reasons. The
principal motive was to improve their living conditions, which were “bad”,
because of Gilberto’s troubles finding work with decent pay. In relation to this
Carmen’s mother-in-law, Aurora, who was present during the interview,
mentioned that Gilberto’s education (diploma técnico) was not worth much,
since they had not had the money to get his diploma. Besides this there were
no qualified jobs in Cuatro Santos, Aurora said, so the family remained poor.
Carmen also mentioned some more direct reasons for Gilberto’s migration –
they needed to repay money they had borrowed to cover some medical
expenses (health was thus indirectly involved), and also wanted to build a
house of their own. They had a piece of land just up the road from Gilberto’s
parents’ house where they had started construction, but they had not yet had
the money to complete it. Carmen and Gilberto reasoned that he would be able
to make much more money if he went abroad, which could help them meet
their needs sooner than if he remained in Cuatro Santos, where the only job
he could get was as a helper on a bus, which gave very little money. A third
155
motive for migrating, which Carmen and Aurora mentioned later in the
interview, was that Gilberto wanted to help his sister pay his niece’s school
fees. Even though his sister was working in El Salvador, she was not making
enough money to pay for her daughter’s education herself, and Gilberto
reasoned that it would benefit him and Carmen to help with the cost (as an
investment in the future). So, Gilberto went (undocumented) to the US.
Carmen:
“He [her husband] left because there was a lot of trouble [mucha jarana]…
We had borrowed money to cure the girl… And also, so that we could build a
house… Well, to help us, because here we couldn’t make it any further [no
podia más hacerlo]. So, for this he left. […] He also has a niece who’s studying,
and he said he would help her with the costs, since her mother is poor; she’s
working in El Salvador but makes little money, so he had to help her. […] So,
he left to…to…maybe to…help himself…get through life [pasar la vida]…since
we lived a bad life here, because he almost never worked… And now when he’s
there, he makes money, and we live on…”
Upon my question of whether Carmen and her family received any kind of
support from outside the family, she replied that she did not experience the
community as very supportive, but that help was mostly provided within the
closest family. According to Aurora, Carmen’s mother-in-law, one reason for
this was the poverty: “Even if people want to help each other, and say they
will, they can’t”, Aurora said.
Carmen’s husband Gilberto had thus left for the US because the family needed
more money to satisfy their needs, which would not be possible if he stayed in
Cuatro Santos, due to the difficulty finding work with decent pay. They also
experienced a lack of social support, and the structural problems – poverty,
unemployment, low incomes, etc. – could therefore not be solved individually,
through helping each other out. Joanna’s story highlights similar issues.
Joanna, 28 years old, lived with her two children in a small town in Cuatro
Santos. She had been raised by her mother in the area where she now lived.
When Joanna had graduated from secondary school she met her husband,
who was working as a truck driver travelling all over Central America. He had
spent a great deal of time in Guatemala, and Joanna decided (against her
mother’s wishes) to go there with him. One of her brothers was also living
there by that time, as were numerous friends from her hometown. Joanna said
that the main reason they all left Cuatro Santos was that there were no jobs in
the area, and thus no possibility to make a living. In Guatemala, on the other
hand, there were more job opportunities, with higher salaries. Joanna’s
personal motivation was to make money so that she and her husband could
buy a house of their own in her hometown. So, for seven years she worked in
an assembly plant, while her husband continued driving his truck. Over the
156
years they had two children. Finally, after seven years, they had managed to
save enough money to make their dream come true, and Joanna and their two
children could return to Cuatro Santos to their new house. Even though they
had thus accomplished their dream of acquiring a house of their own, Joanna
emphasized that they had not become rich through their endeavours. Her
husband continued working as a truck driver in order to support the family.
Joanna:
“I went to work in Guatemala, because my husband was there, working there.
We worked there, in order to make a start, to buy a house. Here you can’t do
anything other than agriculture [uno no pasa lo que es la agricultora] and you
don’t have anything to build on [uno no tiene para hacer sus cosas], so one
looks in other directions [uno busca para otro lado], to other countries, to
make it. For this reason we were there for a long time. […] Here, life in
Nicaragua, here there are fewer jobs, and a bit more difficult.” <<C: Did you
manage to do anything else with the money you made in Guatemala?>>
“No…the only thing we made was our house. That we would have become rich
[Que si hemos hecho riqueza y grandeza], no… […] He [her husband] is still
working in order to feed the children, but, only for that. But yes, he keeps
working so we won’t lack food, things like that, that are related to the
household… But that we would have money… [laughs] no.”
Joanna thus stressed that, even though they had managed to acquire a house
of their own, they had not made a fortune from working in Guatemala. Now,
through her husband’s continued work, they only had enough for their
sustenance. Upon my question of whether she received help from anyone else,
Joanna said there was a strong sense of unity in the community, and that
people helped each other out, for instance when someone was sick.
Joanna:
“Yes. My mother-in-law is always checking to see how the baby’s doing, that
he has what he needs, makes him [traditional] remedies [remedios caseros]
also. We’re all united…in all types of problems, illness, and other things, we’re
always united here.” <<C: Is it mostly family members who help each other,
or do neighbours and friends help each other too?>> “Here, in this village,
people are very…how should I say…charitable [caritativa]. Well, they’re very
united… People are very united, loving [cariñoso], they love each other very
much…”
Despite this sense of unity and support, Joanna had thus experienced the need
to migrate to Guatemala in order to achieve her goals in life. Now, when these
goals had been accomplished, she had no plans to go abroad again, even
though their income was just enough to feed the family.
Hence, Joanna and Carmen in Cuatro Santos, as well as Juliano, Cindy and
Cesar in León, all talked about migration as a necessity due to unemployment,
few job opportunities and low incomes – regardless of the social support at
hand. Their stories show that migration was performed in order to make a
157
living, when opportunities were few in Nicaragua – thus, a practice of mobile
livelihoods.
Sole breadwinner
Marta and Maribel, whose stories will be examined next, not only experienced
the troubles making a living in Nicaragua due to unemployment and low
incomes; they also shared the predicament of being the sole breadwinner.
Marta, who was 50 years old, was born in a rural district to the north of León,
and had worked for many years as a maid in central León. She came from a
poor family, and had been raised by relatives since her parents had died when
she was a child. The family made their living as farmers, and supplemented
their income by working on cotton plantations. When Marta was around 20
years old she separated from her first husband, with whom she had two
children. In order to look for work and make a living for herself and her
children, she moved to León where she could stay with relatives. As she did
not like the hard work in the fields, she was content when after some time she
found work as a cleaner in León.
Marta:
“I came here [to León] because I had separated from the father of my eldest
children. And so…I decided to come here to look for work, to work here in
León… And a cousin of mine who lives here in León looked after me. I came,
looked for work…and started working…that’s it...”
Marta’s migration was thus primarily motivated by her need to look for work
after separating from her husband. She was then solely responsible for
supporting and taking care of her children. Marta’s story can be understood
in relation to prevailing gender structures and norms of parenting in
Nicaragua, which entail that mothers assume much greater responsibility for
the household’s social reproduction, including child care (Martínez Franzoni
& Voorend 2011), as mentioned earlier. At the time of the interview Marta was
leading a very settled, satisfied life in León, and had no intention to move
anywhere else, even though four of her siblings lived abroad (two sisters in
Costa Rica, one brother in Honduras, and another brother in the US).
Maribel, 39 years old, was born and raised in León, where she also presently
lived with her two teenage children. Maribel had separated from the children’s
father ten years before our interview because of his alcohol problems. Since
the separation, Maribel, a trained nurse, had continuously struggled to find
work in order to support herself and her two children, and to help her elderly,
sick parents. She had worked for many years in different public and private
health services in León, as well as in other parts of the country. She had also
158
worked for a government institute in Managua for a couple of months. After
this she encountered economic problems, and her mother borrowed money
from the bank in order to improve her small business. For about four years,
Maribel had lived in Costa Rica, where one of her sisters also lived, and had
worked in several different jobs – at factories, restaurants and hotels. During
these years, Maribel’s mother and siblings looked after her children. Upon her
return, she went through a period of unemployment before finding a job in the
health care sector. She supplemented the income from that job by working in
her mother’s small business at the market, which her mother could not
continue doing due to illness. Nevertheless, Maribel almost did not make
enough money to make ends meet. She was in a difficult situation, but at the
same time did not want to go back to Costa Rica.
Maribel:
“After that [the period in Managua], I had economic problems. My mother
took a bank loan to improve her business so that she could earn more money.
After that I went to Costa Rica. […] When I returned, I went looking for work.
My mother sells soup, that’s her business, and I told her to rest, that I would
do it, so I work with that business on the weekends. From Monday to Friday I
work with the organization [a health care project], through this I earn more
money. […] Sometimes I was desperate, and I wanted to go back [to Costa
Rica]… But then I found this job and I could stay [in Nicaragua].”
Maribel was thus a single mother, solely responsible for supporting herself
and her two children, which like Marta’s experience should be seen in light of
Nicaraguan parenting/mothering practices (see above). Migration for work
was integral in her strategies for making a living, both within the borders of
Nicaragua and abroad (thus a practice of mobile livelihoods). Even though life
was hard in Nicaragua, Maribel said she did not want to return to Costa Rica,
because she did not want to leave her children; since she had a job in León she
also had the possibility to stay close to them. (I will return to this in relation
to health-related motivations for moving and staying). Maribel’s highest hope
was that she would be able to continue working (in Nicaragua), so that her
children could get an education.
Hence, Nicaraguan gender structures and parenting practices place major
responsibility on Nicaraguan women for the upbringing and care of children.
Marta and Maribel migrated as a strategy for assuming the role of
breadwinner upon separating from their children’s fathers. In Maribel’s case,
migration also entailed separation from her children, an issue that will be
discussed further in Chapter 7.
159
Striving to move forward in life – “seguir adelante”
In relation to the difficulties making a living, several interviewees talked about
how they wished to improve their situation in order to “move forward”
(seguir/salir adelante). Steel, Winters and Sosa (2011) state that seguir
adelante is commonly expressed in Latin American countries in relation to
enhanced well-being, and that it “reflects the popular belief that mobility is an
important means of escaping poverty” (p. 401). However, as Leinaweaver
(2008: 62) writes, seguir adelante “is not purely an economic achievement; it
is not only about overcoming poverty. It has well-documented moral
connotations”, and entails “the morality of improving oneself, a project that
requires overcoming the negative associations of poverty through dedicated
efforts at getting ahead” (p. 72). The phrasing should thus be understood in
relation to poverty and its many ramifications, and involves “betterment”; i.e.
the process of “improving oneself”. Moreover, it is related to both social
mobility and migration, and is an important motivation for both. Education is
often seen as the main way to move forward (ibid.). Seguir adelante can thus
also be related to the issue of class consciousness; for the wish to change life
for the better, and thus to climb the social ladder, is often integral in the
identities of the lower social classes (see e.g. Felski 2000). In Anna
Johansson’s (1999) study of a Nicaraguan neighbourhood, several informants
talked about seguir adelante, and stressed the importance of work and
children’s education in order for them to have a better future. The
interviewees in this thesis also stressed work and education as means of
moving forward.
Mercedes, for example, talked about how she had been forced to fight in order
to improve their living conditions and “move forward”, primarily for the sake
of her children.
Mercedes:
“I’ve fought for my things, in order to graduate, and I’ve been fighting because
I want to better myself [superarme], I want to move forward [salir adelante]
so that my children won’t have to go through what we’ve gone through. So I’ve
been working, making some money for the food, for my business….we’ve been
fighting like that. […] Of course…I wish to have an improvement [superación
mejor].”
Carmen in Cuatro Santos, in response to a question about the future, also said
that her main hope was to “move forward” in life.
Carmen:
“Hope for the future? To move forward [seguir adelante] [laughs]… Well,
move forward to…to improve our life…” <<C: And what does “seguir
adelante” mean to you?>> “Mmm… Well, to work, to…keep on fighting. Work
and create calm…to raise our children…to give them what they need.”
160
Carmen thus stressed work, and the struggle to provide for her children, as a
way to move forward and improve life.
Rosa also emphasized in our interview how, despite all the difficult times she
had gone through, she had struggled hard so that her children would be able
to “move forward” and have a better future. Her highest hope was that her
children would be able to get what she did not get as a child – an education.
Rosa:
“I pray to God that he keeps helping me forward, that he gives me the strength
to always move forward [seguir adelante], in order to take care of my children,
to always have the energy to continue working, for my children. […] I have to
work to be able to feed them. […] I have to work, work for them, in order to
see a future for them. So that my children can move forward in life [que siguen
adelante]. Because…what I think about, is to continue working so that they
don’t stop studying. […] I couldn’t study, so I want them to study as far as they
can, so that they get an education, and that I keep working so that I can see a
better future.”
Rosa’s narrative can also be related to Nicaraguan mothering practices, i.e.
what is generally expected of mothers in Nicaraguan society – to be selfsacrificing, and to fight for the survival of their children (see Mulinari 1995;
Johansson 1999). Being a hardworking woman and taking care of the house
and its members, especially ensuring the children’s physical survival and
attending to their “moral” upbringing, is indeed central to Nicaraguan
mothering practices. Even though a collectivist approach to mothering
(shared mothering) – which involves the sharing of child-rearing
responsibilities with others, primarily female family members (e.g.
grandmothers, “godmothers”/comadres, aunts), as well as the children’s
fathers – is common in Nicaragua, as in Latin America in general, because the
economic conditions often necessitate it (Nicholson 2006), Nicaraguan
mothers assume much greater responsibility for the household’s social
reproduction (Martínez Franzoni & Voorend 2011; see also Winters 2014, on
translocal carework practices among rural Nicaraguans that shape livelihood
and mobility patterns).
Besides expressing hopes for the future, for some interviewees seguir/salir
adelante was also a motive for migration. Santos, for example, stressed the
wish to “move forward” and “become someone” as reasons behind his
migrations.
Santos was a 33-year-old Leónese who was working as a security guard at a
shop in León at the time of our interview. He was not married, but rather still
lived with his elderly parents, who depended on him for support. Santos had
only completed primary school since the family could not afford to keep him
in school. He started working at an early age, in León as well as in the
161
countryside. Santos nevertheless had always had difficulty finding work, and
the jobs he did manage to get had always been on a short-term basis and with
low pay. He also said he had always had to fend for himself, and that he was
the only one of his siblings who helped their elderly parents. Even though he
had relatives in Grenada, Managua and Costa Rica, he did not feel he could
turn to them for support. He experienced a lack of a supporting social network,
and had therefore felt forced to migrate. He had made several attempts to go
abroad – twice to the US and once to Costa Rica. However, on all three
occasions he had been caught by border patrol and immigration police and
deported to Nicaragua, either when crossing the border or after a couple of
days in the new country. Hence, due to his undocumentedness, Santos did not
manage to change his life situation for the better. Understandably, he was
rather negative about his migration experiences.
Santos:
“In our family, we’re…humble workers, we’re poor… […] I didn’t continue in
school for economic reasons… […] Now, I’m ignorant, I’m an ignorant
person…I don’t know anything… […] I walked the streets of León a lot, looking
for work…anything. Now, I have this job for six months, but then I don’t know
what will happen. […] I’m a simple worker who wants to move forward in life
[salir adelante]… […] You have to try to become someone in the future [debe
buscar como ser alguien en el futuro]. […] I had a dream, I tried to follow it,
but I failed. I feel bad because…I tried to change things…and I failed. We
returned here without money, without clothes, hungry… It’s a risk you have to
take in order to move forward [salir adelante].”
Santos’ narrative clearly shows that seguir adelante also has moral
connotations, as mentioned above. He emphasizes that he comes from a poor
family, and is therefore “ignorant”. Because of his troubles making a living,
and in order to look for work and new opportunities in life – so that he could
“move forward” (salir adelante) and “become someone” (ser alguien en el
futuro) – he had thus attempted to emigrate. But, in his words, he “failed” and
therefore did not manage to change his situation. To my mind, Santos placed
a great deal of responsibility on his own shoulders in order to improve his
circumstances in life. His narrative shows that the individual often has limited
powers in the face of constraining structures, even though actions are
undertaken to accomplish change. Despite his negative experiences, in 2008
(a year after our interview) Santos mentioned to me that he was thinking of
making a new attempt to go to Costa Rica, in order to improve his economic
situation. However, he was waiting for a migrant work agreement to be
approved, since he did not want to travel undocumented again. This points to
the important role migration policies and border politics play in people’s lives
and their chances to migrate, as well as their experiences from it (the issue of
borders and border politics will be discussed more in Chapter 6).
162
In this section, I have discussed two of the main motivations behind migration
decisions I identified in the interview analysis – the troubles making a living,
and the aspiration to move forward in life (seguir adelante). The described
migration practices fit very well into the concept of mobile livelihoods, since
this conceptualizes migration in relation to people’s strategies for making a
living. In the study setting, migration is an important livelihood strategy when
opportunities fail to present themselves in Nicaragua. I have shown that the
interviewees in this study practice translocal livelihoods, involving different
places in both Nicaragua and other countries, and different actors, often
within the same household but in different places involved in the migration
process. The qualitative interviews clearly showed people’s vulnerable
situation, and their suffering, in the face of poverty, insecure livelihoods and
the environment, for example, as well as the crucial need for help from
personal social networks or development co-operation for getting by. I also
showed how women may migrate as a strategy for assuming the role of
breadwinner in relation to the fact that Nicaraguan gender structures and
parenting practices place major responsibility on Nicaraguan women for the
upbringing and care of children. The complexity of migration motives was also
highlighted in the section, and I showed how health can be embedded in the
economic factors that necessitate migration. More specific health-related
motivations for moving and staying will be discussed next.
Particular health concerns as motivating factors
In this section, I will go into a bit more detail regarding the motivations for
moving and staying that were more specifically related to health, even though
it is naturally difficult to single out health-related motivations from other
types, since health is integral in all our actions. The survey study showed that
very few (just 2%) of the respondents with intentions to migrate mentioned
health as a direct reason for migration (see Figure 10, p. 139). Yet, the
qualitative study showed that health was often mentioned as an indirect
motivational factor, and sometimes, that health issues were very much
integral in the decision to move or stay, for many different reasons.
Moving or staying because of health problems
Several interviewees said in the interviews that a particular health problem
had motivated acts of migration or staying. For some, it was personal health
problems, and for others it had to do with the health concerns of a significant
other.
163
Cesar’s mother was sick with diabetes, and had lost most of her sight. Her
medicines were very expensive, and she needed new glasses. Because of her
condition she could no longer work, in either Nicaragua or Costa Rica, where
she had been working for much of her life, and she therefore relied on Cesar,
his sister (who worked in Managua) and a younger brother for support. Cesar
had problems with his own eyes as well, and needed to buy glasses for himself.
As seen in the quote below, he believed that the only way he could make
enough money for new glasses was to either acquire a taxi sign (mentioned
earlier) or get a more serious job in Nicaragua. However, as mentioned earlier,
he believed that the only way to acquire a taxi sign was to go abroad, and he
furthermore did not believe he would be able to get a serious job in Nicaragua.
Migration was thus the only option if he was to improve his own as well as his
mother’s health situation.
Cesar:
“My mother isn’t thinking of going [to Costa Rica] anymore because she’s very
sick, and she can hardly see. She says to me ‘I can’t travel, only you. You should
go again, so that you can help me’. […] And, I have to buy glasses for myself.
But the glasses are very expensive… What happens is that today without the
taxi sign or a series of more serious work…I can’t buy these glasses.”
Cesar’s mother was thus too sick to migrate, which made it necessary for Cesar
– who was healthy, though in need of new glasses – to migrate. In this case,
the health situation was a crucial factor behind the move – i.e. a kind of health
selectivity in migration (see e.g. Jatrana, Graham & Boyle 2005; and Gatrell &
Elliott 2009). However, the move was not isolated to one individual’s
migration decision but rather took place within a strong mother-son
relationship of mutual support and responsibility. Cesar’s mother in fact
“ordered” him to migrate in order to improve their situation, a strategy she
herself had successfully used earlier in her life. Cesar’s narrative thus shows
that migration may take place as part of intergenerational learning processes.
Maribel was a single mother, responsible for supporting herself and her two
children, as mentioned. She had been working in Costa Rica for about four
years because of difficulties finding a job in Nicaragua. Her last visit to Costa
Rica took place about two years prior to our interview. The reason behind her
return to Nicaragua at that point in time was that her son was in “trouble”,
and also that her mother, who was sick with diabetes and relied on Maribel
and her siblings for support, was in a worse situation healthwise. Upon her
return to Nicaragua, Maribel decided to stay and take care of her mother.
Maribel:
“I came back because my son needed help, I couldn’t let him live on the street,
he’s 19 years old, he needs care and support. […] My mother called me and
told me, and I also visited my sister there [in Costa Rica] and she said that my
son was drinking [andaba tomando]. It was because of this that I went home.
164
I said to myself, I won’t let my son get corrupted just to earn a little money.
[…] And, [I returned] also because of my mother, who is sick. […] Then I
stayed [in Nicaragua] because my mother got worse, she was really bad, so I
stayed here.”
Nevertheless, as mentioned earlier in the chapter, Maribel faced a difficult
economic situation, and almost did not make enough money to make ends
meet. But, she did not want to go back to Costa Rica and leave her mother, and
she also wanted to stay close to her children, who she believed needed her
attention. She was particularly worried about her daughter.
Maribel:
“I said to myself that the situation here is difficult, but I don’t want to go, and
leave a 16-year-old girl, that’s a dangerous age. ‘I go, I stay’, that was the
dilemma; thank God I found this job.”
Maribel’s narrative thus also highlights how her role as a mother implied that
she was responsible for her children’s care. She particularly shows concern
over her teenage daughter, implicitly over her reproductive health. These
worries are legitimate in the study context, as in many societies. In the
Nicaraguan case, research has shown that according to the general discourse
on men, women and sexuality, women are seen as being in need of protection
and seclusion in order to maintain their sexual “purity” (virginity and fidelity),
so that men’s “honour” and masculinity can be guaranteed (Johansson 1999;
Mulinari 1995)143. Especially young women are regarded as being in danger of
being assaulted, raped, or even murdered by “uncontrolled” men if they are
out on the street, as this is a highly masculine and sexualized space in
Nicaragua (Johansson 1999). Based on this, Maribel’s concern over her
teenage daughter is understandable.
In all, health issues were important to Maribel in the decision to return to
Nicaragua, as well as to stay there. She expressed gratitude and relief at having
acquired a job that meant she could remain in Nicaragua, so that she could be
close to her mother and children, which would thereby enable her to take care
of them. Maribel’s narrative thus points to the importance of gender,
parenting and care practices in migration decision processes.
Rosa also mentioned her children’s well-being as a motivation for staying in
Nicaragua. Before our interview she had gotten a good job offer in Costa Rica
that would give her a much higher income than she had at her current
workplace. She was therefore tempted to go back to Costa Rica, but since her
youngest son had just recovered from an illness, she decided to stay in
143 This is intimately connected to the dominant gender structure (machismo/marianismo) (see Footnote 141).
165
Nicaragua (the boy’s health problems will be discussed more in Chapter 7).
Rosa was also pressured by her brother-in-law to stay for her children’s sake.
Rosa:
“I was about to go again [to Costa Rica] just recently, like in December, but as
it turned out one of my brothers-in-law told me ‘think about your children’s
situation’. I said to myself that I didn’t want it; if something bad happened I
wouldn’t be able to forgive myself. I didn’t go, but I already had a job then, but
there [in Costa Rica] I would have earned more. But, I didn’t go; I said to
myself, it’s true, my boy has just recovered from that illness. Perhaps I’ll go
later.”
The well-being of Rosa’s children, and the importance of being a “good”
mother to her children – even in the eyes of others (i.e. her brother-in-law) –
were thus more important to her than the possibility to make more money,
and were therefore major reasons for her decision to stay in Nicaragua.
However, Rosa seems to have gone through rather ambivalent feelings in this
decision-making process, which probably caused stress (the issue of emotions
and health relations is discussed further in Chapter 7).
Another interviewee who mentioned health concerns in relation to migration
decisions was Carmen. Carmen’s husband Gilberto had gone to the US to
work, and one of the reasons behind his move was that they needed money to
repay a loan they had taken for medical expenses in relation to their daughter’s
eye problems. Moreover, Gilberto had been forced to stay in the US longer
than initially planned because he suffered from diabetes and was therefore
unable to work as much as desired, and hence make the money necessary for
him to return.
Furthermore, Fernando, whose wife was in Spain, had gone to the US to work
before she left. However, after six months he had been forced to return home
due to ill-health. Fernando suffered from both diabetes and high blood
pressure, and his health condition had deteriorated due to the hard work (in
construction) and the hot climate. He was nevertheless very glad to return,
because he found it difficult to be away: “It’s hard to be away from one’s family,
home and country”, he said. In Fernando’s case, health was thus a “legitimate”
pretext that led him to make the difficult decision to return.
Returning because of fear of crime and violence
In several interviews, fear of crime was mentioned as a reason behind the
return to Nicaragua (or, for example, the return to León from Managua, if
internal migration had been undertaken).
166
Joanna, who had worked with her husband in Guatemala for seven years in
order to acquire a house of their own in Cuatro Santos, had returned with her
children to Cuatro Santos when this dream was accomplished. The fact that
she and her husband had managed to get their own house was thus an
important motive for her return to Cuatro Santos. However, upon my question
about why they had returned, she also indicated that her fear of the crime in
Guatemala was also central in their decision.
Joanna:
“[We returned] because we already had our house. And, because of the crime
in Guatemala…because of the criminal gangs [las maras]. I was afraid to be
there, with the children…” <<C: Did anything happen to you?>> “No… I saw
cases on TV, everyday you saw things, and it scared me. Well, since I already
had my house…”
Even though nothing had happened to Joanna directly, her fear of the gangs
in Guatemala (las maras) is rather well-founded and understandable, since
these gangs – for example Mara Salvatrucha and Calle 18, which have
evolved in Central America since the 1990s in step with the return of deported
young gang members from the US – are involved in a great deal of violence,
especially in Guatemala, El Salvador and Honduras, and create feelings of
insecurity among the population (see e.g. Aguilar & Carranza 2008; Cruz
2005).
More direct, or acute, health concerns were also mentioned in the interviews,
for example by Marta and Ana.
Staying because of fear or worry
Marta, who had moved from the countryside to León with her children upon
separating from her first husband, met a new man after a couple of years. She
spent the next 23 years as a housewife, having three more children. During
these years she lived in constant fear of her husband, who beat and maltreated
her. One day ten years prior to our interview, when the children were grown,
Marta’s husband decided to go to Costa Rica and look for work in order to
improve their living conditions, Marta believed.
Marta:
“I met this old man…the father of my other three sons…and I stayed [in León].
[…] Well, he left [to Costa Rica]…to improve the situation. […] He left…I didn’t
ask why… But, once he told me that it was because of the situation we were
living in, to repair the house...”
Shortly after his departure, Marta’s husband asked if she would join him in
Costa Rica, but she declined since he had treated her so badly throughout their
relationship. Due to the violence she had suffered Marta thus decided to stay,
167
and was in fact relieved rather than sad when he left (this will be further
discussed in Chapter 7). Marta’s story highlights the widespread violence
against women in Nicaragua, which is a serious public health problem that has
received attention during the last decade (Ellsberg 2000; Valladares Cardoza
2005; INIDE 2008; see Chapter 4).
Marta had a relatively large migration network, but despite this she never saw
migration as an option when looking for ways to make a living for herself and
her children. She reasoned that the higher income she might earn abroad was
not worth the risk of being so far away from her children, in case something
were to happen to them or to herself.
Marta:
“I don’t believe I’ll go abroad… <<C: Why not?>> “I don’t know… Not even
with my children being big… It seems to me that something will happen to
them…or that something will happen to me over there…and they, how will my
children cope [carrear]… So, this makes me think… It would be to give my
children problems… I know I might earn more money… No, I’ll only go there
and work…not richer, nor poorer.”
Marta’s worry over her children’s and her own well-being was thus a reason
for her staying in Nicaragua, and can be seen as an expression of mothering
practices. In all, the interview with Marta showed that emotions (in her case,
feelings of a lack of safety and worry) were in play as underlying motivations
for staying.
Moving away from sexual abuse
Ana, who was 22 years old, had recently moved to León where she worked as
a housekeeper. Before moving to León she had worked for seven years in a
smaller town to the north of León, also as a housekeeper. She had arrived there
at the age of 15 after having left her birthplace, a small, poor, rural community
“in the mountains”, far away the coast. There, her family made a living as
farmers, living on what they produced. Ana had five brothers, who were still
living at home; over the years nine other siblings had died during infancy and
childhood due to illnesses. Ana describes her home area as forgotten by the
state and international organizations, and therefore with lacking health care
services and schools. Ana had never gone to school because her mother did
not want her to, because of the risks it might entail (her mother argued that
Ana might be attacked by ladrones/“bad guys” because of the long distance to
school). Ana herself reasoned that she was not allowed to go to school because
her mother and brothers wanted her to be “kept hard”, not even letting her
have friends. This can thus be related to the prevailing Nicaraguan gender
discourse, which emphasizes the need to protect young women facing danger
“on the street” (Johansson 1999).
168
The fundamental reason behind Ana’s decision to migrate was a conflict
within the family. In the interview she indicated that something had happened
in her relationship with her brothers, and that she was blamed for what had
happened. She also mentioned that she had previously gone to live somewhere
else for a whole year. All this taken together made me believe that what Ana
was really hinting at was that she had been violated by someone in her family,
and that she had become pregnant and was subsequently forced to leave home
for a while to hide the pregnancy. When I asked her employer about this later,
she concurred that this was in fact what Ana had told her had happened; that
after having been sexually abused by her father she had become pregnant.
After this tragic event a conflict arouse in the family, in which Ana was blamed
for what had happened. She said that the whole situation made her feel bad,
like an “outsider” in the family, and reasoned that it would be better for
everyone if she left, so that there would be no more problems. It was a sacrifice
she had to make, and one she was willing to make.
Ana:
“I was 18 or 15 when I took the decision… No, I said, I’m going…I have to get
out of this place. […] I felt…bad, right. Because…I felt detached [alejada] from
the family, and from my brothers, right. […] I said, they feel bad about me [se
sentían mal conmigo], my family, my brothers, so… I’ll…move away from
them, it’s better, because if they feel bad about me, I said, better not [stay].
[…] This problem has always been there in my family… I had problems… They
made me a problem within the family [me hicieron una problema asi entre
mi familia], and then…they said it wasn’t their fault, that it was all my fault.
So, I felt bad, because my family gave me this problem [me acosto de
problema], they did it, I didn’t do anything wrong… There…when I was where
my family lives, I spent a year away from my family, right… […] I said to myself
that it was better if we lived apart, that perhaps we wouldn’t have more
problems then… So I said that I would make the sacrifice to move away from
my mother, right.”
Ana’s story highlights a very serious problem that is seldom discussed openly.
According to Elmer Zelaya Blandón (1999), Nicaraguan families often hide
sexual abuse, but it is nevertheless widespread. His research has shown that
early pregnancy is associated with the sexual abuse of children and teenagers
in Nicaragua (see Chapter 4). Johansson (1999) also refers to the sexual abuse
of girls in Nicaragua. In her study, girls were seldom left alone at home,
because male relatives and other men were believed to pose too great a risk to
them. Thus, in contrast to what the Nicaraguan discourse on femininity,
masculinity and sexuality would have us believe, the house is no safer than the
street for young girls.
Towards the end of our interview Ana said she had managed to reconcile with
her mother, and therefore wished to move back to her home village. However,
she did not believe this was possible, since she did not “feel good” around her
169
brothers. In 2013, on my last field visit, I learnt that Ana’s father had passed
away and that she had managed to also reconcile with her brothers, and
thereafter had moved home again.
Marta and Ana’s stories thus show how the widespread violence toward and
abuse of Nicaraguan women also influence acts of moving and staying.
Complex migration-health relations: natural disasters, childbirth, longing,
and fear of violence
The interview with Rosa brought up several interesting connections to health,
and clearly shows the complexity of migration-health relations. First of all,
Rosa had been forced to move twice because of natural disasters. A volcano
eruption first obliged her and her family to move to a new town when she was
a child. And then, many years later, her husband died in Hurricane Mitch,
which made her move with her children to an area where humanitarian aid
was available. Prior to this, during the years when Rosa and her husband were
working in Costa Rica, both of her returns to Nicaragua were connected to it
being time to give birth to the children she was expecting. (Another female
interviewee, Esmeralda, had also returned to Nicaragua when it was time to
give birth to her child). Many more years later, Rosa had again gone to Costa
Rica to work, but had returned home after only six months because she could
not endure the separation from her children. She then went to Managua,
where she worked as a maid, but returned after a month because she did not
feel safe there. Fortunately, Rosa’s mother was supportive of her decision,
which made the return somewhat easier for her.
Rosa:
“I was there [in Costa Rica] for six months, but I couldn’t endure it, because I
missed my children…I suffered a lot for their sake, I wondered how they were
doing, I suffered a lot. And, so, I couldn’t restrain myself, I returned. […] I
returned from Costa Rica, I rested a month, and then I went to Managua, to
work in Managua. In Managua I was really scared because la señora [the
employer] said to me, it was 9 o’clock at night and she sent me to the shop, it’s
very dangerous in Managua, and she said to me ‘Look at them over there’, a
lot of men, ‘if they talk to you, you don’t answer, because they’re gang
members [pandilleros], if you look at them they’ll follow you’… I felt like I had
my heart in my hand [el corazón lo caminaba en la mano] when I was about
to go… […] When I returned to my mother, I told her everything that had
happened. And so one day my mother said ‘Come home, your children won’t
die of hunger, there’s always rice and beans’.”
In the quote Rosa emphasizes how she suffered due to the separation from her
children. Suffering is a concept that embraces many negative emotional
experiences, i.e. “feelings of depression, anxiety, guilt, humiliation, boredom
and distress” (Wilkinson 2005: 16-17). Yet, suffering is a wider concept than
170
this; it relates more generally to “experiences of bereavement and loss, social
isolation and personal estrangement” (ibid. p. 16). Every aspect of life can
indeed entail suffering; “[p]eople are held to suffer under the yoke of material
deprivation, with the perpetuation of social injustice, and from the denial of
civil liberties” (ibid. p. 17)144. Suffering is thus a holistic concept that captures
“the vulnerability of lived experience” (Wilkinson 2005, with reference to
Turner and Rojak 2001). Helman (2007) further states that an entire
population can experience social suffering, for example when a nation is under
collective stress due to extensive migration. In the context of this study, the
narration of suffering can also be connected to prevailing gender norms. As
Anna Johansson (1999) writes, Nicaraguan mothers, and women in general,
are portrayed and portray themselves as hardworking, self-sacrificing, and
suffering – because of the hard work that is bestowed on them, and due to the
“irresponsible” machistas in their surroundings. That Rosa says she suffers
from being separated from her children may thus be seen as what is expected
of her to express as a mother. However, it may also be a highly concrete feeling
that very well may have negative effects on well-being/mental health; at least
if emotions are seen as embodied, as proclaimed in the sociological theories
of emotions and embodiment mentioned in Chapter 2 (see e.g. James & Gabe
1996; Williams & Bendelow 1996; Lupton 1998; Barbalet 2002), and if
emotions are seen as important factors influencing health, for which
psychological and social psychological research shows evidence (see e.g.
Folkman 2011; Pennebaker 1995; Lazarus 2006; and Part VII in Lewis,
Haviland-Jones & Feldman Barrett 2008). The issue of mothering in
translocal and transnational contexts will be further discussed in Chapter 7.
Rosa’s story also shows that feelings of unsafety may influence migration
decisions. Even though the more violent criminal gangs are situated in other
Central American countries (El Salvador, Guatemala, Honduras), there are
still gangs in Nicaragua, particularly Managua – where Rosa worked for a
period – and Chinandega. León is often said to be the most secure town in
Nicaragua, just as Nicaragua is proclaimed to be the safest country in Central
America (according to several interviewees and others that I came across
during the study). When coming from a secure place and confronting the
criminals in Managua, like Rosa did, fear of violence may naturally arise.
Hence, the interviews clearly showed that health concerns could be directly
influential on the decisions to move, stay, or return. For some, a particular
health problem (one’s own or that of a significant other) motivated acts of
migration or staying, either of a less serious kind (e.g. loss of sight) or a very
144 See also Bourdieu et al.’s classic “The Weight of the World”, published in 1999, which documents the
“positional suffering” and despair of the French working class, because of a lack of recognition and low social
standing.
171
serious kind (e.g. sexual abuse, death or injury due to natural disasters). Fear
of crime and the emotional pain of separation (suffering) were two other
examples. Even though very few in the survey study mentioned health issues
as a reason for future migration, the qualitative study showed that health was
often both indirectly and directly in play in the decision-making process,
which previous research on migration motives also highlights.
Social support, remittances and health
The in-depth interviews showed that both local and translocal social networks
were sometimes crucial in times of need. Some interviewees said they had
highly supportive social networks, while others did not feel they received
much support from people around them. For some interviewees,
migration/translocal networks were influential in the decision to migrate, but
for others these networks did not seem to have any major influence on their
decision to move or to stay. For some interviewees, the lack of a supporting
social network in Nicaragua was a motivational force to migrate. Furthermore,
the survey study showed that over a third of the survey respondents
mentioned social reasons for migration (see Figure 10, p. 139). This section
will present results concerning exchanges of help within social networks
(social support, e.g. remittances), and their relations to health. This
information may contribute to the understanding of the living conditions in
Nicaragua, the importance of translocal (i.e. local and transnational) support
networks in the study context, and the connection to the socio-economic and
health-related motives behind migration acts. First I will introduce why social
networks are important for health.
Social networks can be defined as “the web of social relationships that we each
maintain, including both intimate relationships with family and close friends
and more formal relationships with other individuals and groups” (Seeman
1996: 442). It is through these social ties that individuals become socially
integrated into the larger society in which they live. Many studies have come
to the conclusion that social integration and social inclusion are utterly
important social determinants of health, since their opposites – social
isolation and alienation – have been shown to have negative effects on health
(e.g. depression) (Turner 2004; Seeman 1996). According to social capital
theory, it is people’s social investments – i.e. engagement in social relations,
people’s social ties – that create social integration and social inclusion, and it
is argued that the more people invest in society and social relations, the higher
the social capital of society becomes, which creates more social integration
and social inclusion, and better health for individuals as well as societies at
large. In relation to this, research within social psychology has shown that
172
strong social ties and interrelational social support can help the individual
cope with negative life events and stress (Turner 2004; with reference to
Berkman & Syme 1979, and Dohrenwend & Dohrenwend 1981). High social
capital, derived through social integration, has thus been established to be
important for mental well-being, and consequently, according to the idea of
mind/body medicine (introduced in Chapter 2), may also affect physical
health positively (Turner 2004). Social capital is furthermore one of the assets
included in people’s livelihood strategies (Helgesson 2006, based on Rakodi
2002; de Haas 2010, with reference to Carney 1998) (see Chapter 2), and thus
used in order to make a living.
Social relationships/ties and social support are thus two aspects that are
deemed important for health, and for coping with stress. Social support
functions as a “social fund” from which to draw when handling stressors
(Thoits 1995), and refers to the provision of psychological and material
resources within social networks (Cohen 2004). Three types of
resources/assistance are often discussed: (i) instrumental support (provision
of material aid, e.g. financial assistance or practical help); (ii) informational
support (provision of information intended to help the receiver cope with
difficulties, e.g. advice or guidance); and (iii) emotional support (expressions
of empathy, caring and reassurance, providing opportunities for venting)
(ibid.). Moreover, a distinction is also made between perceived and received
social support. There is evidence that perceived social support works as a
buffer against stress, lowering the level of psychological distress, depression
and anxiety (Cohen 2004, with reference to Cohen & Wills 1985 and Kawachi
& Berkman 2001). Studies have also shown that perceived emotional support
may have a stronger influence on mental health than the actual received
support (Thoits 1995, with reference to Dunkel-Schetter & Bennett 1990 and
Wethington & Kessler 1986). The reason for this, Cohen (2004: 677) explains,
is that “the belief that others will provide necessary resources may bolster
one’s perceived ability to cope with demands, thus changing the appraisal of
the situation and lowering its effective stress”. Even though there is evidence
that social support is beneficial for health, it is nevertheless important to
remember that social ties – a fundamental aspect of social support, as well as
of social integration – do not necessarily influence life and well-being in a
positive way (Thoits 1995, with reference to Rook 1992; see also Seeman
1996). The absence of social ties (indicating social isolation) may be a stressor
in itself, and “obligatory” social ties (for example, relations within the family
or at work) can in fact sometimes produce stressful demands. In contrast,
“voluntary” ties (between, for example, friends or members of a church or
other association) often have lighter demands, which may be easier to handle.
Thus, the quality of one’s existing ties seems important (Seeman 1996).
173
According to relational perspectives, migration leads to a situation in which
social relations are stretched out in space (Massey 1994, 2005). Social
relations thus continue despite migration, but are often fundamentally
changed. Social support thereby also changes, taking on a translocal character.
An important part of such translocal social support are remittances – i.e.
transfers of money and goods from abroad or within the country145, which can
be seen as a kind of instrumental social support. Nicaragua has received
increasing amounts of remittances during the period of this study, and they
represent about 10% of the country’s GDP (UNdata, Internet, accessed 201402-13). The share of remittance-receiving households is about 15%, and more
affluent households make up a relatively high share of these (33% of
remittance-receiving households belong to the top income quintile, while only
12% belong to the lowest), as Nicaraguan emigrants are generally part of
households that are not the poorest (Fajnzylber & López 2007). Most
remittances originate from the two most common migrant destinations – the
US and Costa Rica (UNDP 2009) – and are mostly used for consumption (e.g.
food, clothes), health care and education (Morales & Castro 2002).
Based on these theoretical understandings and previous research, I have
investigated the role of social support in the lives of the study participants. On
the following pages, the survey study results concerning help within social
networks will first be discussed, and thereafter attention will be given to
remittances and their role in health in the context of this study, also based on
the qualitative material.
Survey results: help within social networks
In the survey, the respondents were asked a couple of questions concerning
social support – i.e. perceived economic and emotional support, exchanges of
help, and access to social insurance – with the purpose of analysing the types
of social support they had access to, whether migration networks influenced
social support, and the importance of these aspects for health.
The survey results showed that the majority (90%) felt they had someone to
turn to for emotional support (Question 15), and that about two-thirds (65%)
felt they had someone to turn to for economic support (Question 14) (Figure
11, next page).
145 Remittances are generally defined as transfers of money (or goods) from migrant workers abroad to their
family members who are left behind at the origin. In this thesis I use a broader conceptualization, also including
money and goods sent within the country. Financial/money remittances refer to money that is sent. In this
section I most often mean money remittances when writing just “remittances”.
174
Has someone to turn to for
emotional support
90,2
Has someone to turn to for
economic support
65,5
0
20
40
60
80
100
Figure 11: Perceived social support. Weighted percentages.
Based on Questions 14-15, Survey 2008.
Hence, most experienced having social support, which is positive since
previous research (see above) has shown this to be important for health.
However, a third of the respondents did not experience that they had someone
to rely on for material support, which is a more negative result since lacking
social support may decrease an individual’s possibilities to cope with
problems, and thereby increase stress levels. In the study context, where
poverty is widespread, causing endemic stress, the feeling of having someone
to turn to for support may be important, for example for easing the stress of
finding ways to pay for the daily household expenses, e.g. the day’s meals. Not
many people in Nicaragua are in the position to be able to save money but
rather live day by day, which means that many are reliant on support from
others in the case of unexpected events (e.g. illness) (see e.g. Steel, Winters &
Sosa 2011).
However, perceived social support can differ from the support that is actually
received. Research has shown that perceived support is often more important
for health than received support is (see above). In order to examine whether
this was the case in our study population, the survey also included questions
about whether the respondent occasionally received or provided help from/to
someone outside their household (Questions 16 & 18). The results showed that
a fifth (21%) occasionally received help from someone outside the household,
and almost the same share (18%) said they themselves provided help to others
(Table 11).
Table 11: Exchanges of help
All respondents
León
C. Santos
Receives help
21.1%
19.2%
21.9%
Provides help
18.1%
30.9% a
12.3% a
Notes: Based on Questions 16 & 18, Survey 2008. Weighted percentages. a p<o.001.
175
There was no difference regarding the reception of help between the two
settings; however, it was significantly more common to provide help to others
in León. This might be related to the better socio-economic situation in León
than Cuatro Santos, which probably enhances people’s possibilities to help
others. This was in fact highlighted in the in-depth interviews; some said that
even though people wanted to help each other out, poverty was sometimes a
constraint.
Hence, about a fifth of the respondents actually received help occasionally146.
This can be compared to the rather low share who had social insurance –
12%147 – which nonetheless was somewhat higher than the national average
of insured persons (9%, according to Muiser, del Rocío Sáenz & Bermúdez
2011). This difference may perhaps be explained by the higher insurance rate
in León (26%) than in Cuatro Santos (7%)148, which is probably related to the
fact that fewer inhabitants in rural areas work in formal employment (because
there are few such job opportunities in rural areas) – which insurance is often
tied to – but may also be explained by the lower access to insurance offices in
these areas, and the affordability of insurance for the socio-economically
disadvantaged rural population (see Chapter 4). These are important findings,
since those in Nicaragua who are insured generally have better access to health
care (at least to health care of better quality, and at a lower cost). In fact, in
Nicaragua individuals with health insurance receive treatment twice as often
as the non-insured (Angel-Urdinola, Cortez & Tanabe 2008). When insurance
is lacking, the help you can receive from people within your social network
thus becomes important, for example in the case of health care needs. Luckily,
a rather high share (two-thirds) perceived that they had someone to turn to if
economic needs necessitated it. Additionally, the majority felt they had
emotional support, which, as mentioned above, is important for mental
health.
Regarding what types of help the survey respondents received, the results
showed that the vast majority (91%) received money (Figure 12, next page).
Almost a fifth (18%) reported receiving utilities (e.g. clothes, furniture,
appliances), and a smaller share (6%) said that they received food.
146 In 2007 during the first step of our survey, the share of respondents who reported receiving help (i.e.
remittances) was somewhat lower – 16% of all respondents (see Chapter 3, p. 70, for further information on the
first step, and the question posed then).
147 Based on Question 3, Survey 2008. In weighted percentages, for all respondents.
148 p>0.001.
176
90,8
100
(received help=21,1 %)
80
60
40
17,7
20
5,5
0
Money
Utilities
Food
Figure 12: Type of help received. Weighted percentages.
Based on Question 16, Survey 2008.
The majority thus said they received money, which means that the share who
received financial remittances made up almost 19% of all respondents. This is
similar to the levels of remittance-receiving households stated elsewhere
(15%, according to Fajnzylber & López 2007, for example).
Upon the question of what the money remittances were usually used for, the
majority (84%) of respondents mentioned daily needs, e.g. food, clothes and
other living costs (Figure 13). Almost a quarter (23%) mentioned using the
remittances to pay for health costs, and 13% said they spent them on
education.
Other
(received money=18,8 %)
4,1
Education
12,5
Health
22,6
Daily needs
83,5
0
20
40
60
80
100
Figure 13: Use of money remittances. Weighted percentages.
Based on Question 16, Survey 2008.
These findings are consistent with previous research that shows that
remittances to Nicaragua are mostly used for consumption, education and
health care (e.g. Morales & Castro 2002). It is an important result that almost
a quarter (23%) of all remittances are spent on health, and indicates a
substantial lack in the Nicaraguan health care sector when it comes to
providing health care for all. In the presentation of the results of the
qualitative study, I will show how people are engaged in and talk about these
issues.
177
The majority (88%) of those who received remittances did so from someone
residing abroad, and 14% from someone in Nicaragua (9% from another
department) (Figure 14).
(received money=18,8 %)
From someone in Nicaragua
14,4
From someone abroad
87,9
0
20
40
60
80
100
Figure 14: Origin of money remittances. Weighted percentages.
Based on Question 16, Survey 2008.
Even though most of the financial help thus came from abroad, a great deal of
money was also transferred internally, within the borders of Nicaragua. This
is worth attention, and indicates that internal transfers may also be important
for people’s livelihoods. This was also clear in the qualitative interviews, as I
will show later in the text.
Those who received money remittances did so primarily from their children
(42%), or from siblings (26%) (Figure 15). One of ten (10%) received
remittances from their parents, and 6% from partners. A large part received
money from more extended family or others (“Other” in the figure, of which
13% refers to other relatives).
Other
18,5
Partner
6,2
Parent
10,2
Sibling
26
Child(ren)
41,8
0
10
20
30
40
50
Figure 15: Sender of money remittances. Weighted percentages.
Based on Question 16, Survey 2008.
These findings reflect what was shown earlier regarding the respondents’
translocal networks (see Figure 6, p. 132). However, children seem to play a
more important role in sending remittances, in relation to how many reported
having children living in other places (26%). Moreover, the fact that 6%
received money from a partner indicates that the share who have their
partners living in other places is perhaps higher than what was reported (2%),
or that they send remittances more often than other relatives.
178
Help during illness
In order to analyse the access to social support in situations of ill-health, in
the survey we also asked if those who had suffered from health problems had
received help during the illness period (Question 17). Of those who had been
sick three months prior to the survey (which amounted to 50% of the
respondents), over a quarter (28%) said they had received some kind of help
(Figure 16).
35,9
40
28,2
(sick=50 %)
24,8
20
0
All respondents
León
Cuatro Santos
Figure 16: Received help during illness period. Weighted percentages.
Based on Questions 10 & 17, Survey 2008.
Approximately three quarters had thus not received help, which may indicate
a problem since research has shown how important social support can be for
enhancing health. In León, over a third (36%) reported having received help
during the illness period, compared to a quarter (25%) in Cuatro Santos149.
Like the differences in the patterns of help provision (see Table 11), this might
be related to the socio-economic differences between the two study settings,
i.e. that people in León have more possibilities to help others because of the
better economic situation there, including when it comes to needs in relation
to health problems.
Regarding who had provided help during the illness period, the majority
(77%) said it had been provided by someone living in Nicaragua (Figure 17,
next page) (for the most part from people within the same municipality). Still,
over a quarter (27%) also said they had received help from someone abroad.
149 p>0.05.
179
From someone in Nicaragua
77,2
From someone abroad
26,6
0
20
40
60
80
100
Figure 17: Origin of help during illness period. Weighted percentages.
Based on Question 17, Survey 2008.
Moreover, many stated that they had received help from their children (39%),
their partner (27%), or their parent(s) (18%) (Figure 18).
Other
(received help=28,2 %)
8,3
Partner
26,7
Parent
18,2
Sibling
6,9
Child(ren)
39,3
0
10
20
30
40
50
Figure 18: Provider of help during illness period. Weighted percentages.
Based on Question 17, Survey 2008.
These findings stand in contrast to those concerning from where and whom
money remittances, in general, were sent (see Figures 14 and 15). That is,
during periods of illness people close by provided more help, while during
other times in life – under healthy circumstances – people farther away
provided more help. Thus, the individual’s social networks within Nicaragua
seemed more important during illness, which may be related to the easier
access to these resources than to the international networks. Yet, over a
quarter did receive help from abroad, which shows that transnational
networks are also important for easing the illness period. Furthermore,
besides children, partners and parents played a more central role during times
of illness, at least when it comes to providing help. It is perhaps the case that
when more “intimate” problems (e.g. illness) arise – in contrast to those of a
more general kind – individuals more often turn to their closest significant
others. These are interesting findings; what happens when those you regard
as closest to you are not there, for example if they have migrated? Who do you
then turn to if you are ill and need support?
Thus, of the 50% who reported some kind of health problem in the survey,
over a quarter (28%) had received help during the illness period. Regarding
180
the kind of help received, more than half (58%) stated medicine, and another
half (55%) stated money (Table 12). Some (7%) also said that they had received
food, and a few (4%) that they had received care or emotional support. For the
most part (89%), the money was used to buy medicine. About a fifth (20%)
said the money had been used to pay for care at private health clinics.
Table 12: Type of help during illness
Received medicine
58.1%
Received money
55.5%
- used for medicine
89.4%
- used for private health care
19.7%
Notes: Based on question 17, Survey 2008. Weighted percentages.
These findings show, in concurrence with others (PAHO 2009), that a great
deal of private resources are spent on health care expenses, particularly on
medication. Moreover, the findings show that remittances – of which a
quarter was sent from abroad – are also an important part of private
expenditures on health. In such conditions, it is clear that problems exist in
the Nicaraguan health care system that limit the access to health care for a
large part of the population, and that the population’s right to health is not
sufficiently met.
In sum, a large part of the study population experienced that they had social
support, particularly emotional support. Important to note, though, is that a
third of the study population did not experience having someone to turn to for
material support, which makes this group particularly vulnerable in times of
crisis. Moreover, the share who actually received help from and/or provided
it to others was higher than those who had social insurance, which indicates
that the help exchanged within social networks may be of crucial importance
in times of need, for example if health problems arise. The most common type
of help received was money, which was mostly used to pay for daily
consumption, health and education. The greatest part of the money
remittances were sent from abroad, but an important share also came from
other places within Nicaragua, which shows that local resources are also
important for people’s livelihoods. The money was most often sent from
children and siblings. The survey material also showed that a quarter of the
study population who had experienced health problems received help during
their illness period, especially those residing in León. Most had been given
either medicine or money (the latter of which to a great extent had been used
to buy medicine). This is in line with previous research that particularly points
out problems with access to medication in Nicaragua. Most of the help came
from people living close by (within the country, and often within the same
181
municipality). Yet, a quarter received help from abroad, which shows that
transnational social networks are also important in providing social support
during illness. Moreover, the closest significant others (children, partners and
parents) were especially important in providing help.
Qualitative results on remittances
Most of the interviewees with experience of international migration – either
from migrating themselves or from being the family member of an emigrant
– had experiences of sending or receiving remittances. The importance of the
remittances for the household economy naturally varied a great deal. Some
interviewees were completely dependent on money that was earned
elsewhere. Joanna, for example, relied solely on the money her husband made
from working as a bus driver, travelling all over Central America. Cindy also
relied completely on the income Juliano was making in the US.
Cindy:
“Yes, he [Juliano] sends money... Since he gets paid every week, he sends
money weekly in relation to the costs. Because… For paying for the house, the
child’s school fees, the debts we’ve acquired, to buy things, pay for food, things
like that…he sends it weekly. Except for what he has to pay over there [in the
US]…his car, rent, food, all that.”
Upon my question of whether they had been able to do anything they had not
been able to do before, for example improving the house, Cindy explained that
since they only rented the house they lived in they could not make any
improvements to it. But, she continued, with pride:
Cindy:
“What we’ve done is to buy the things we need… My house is fully equipped
with everything – I have my furniture, television, DVD, stereo, my
refrigerator, kitchen, beds, wardrobes… I have everything in my house, I have
everything.”
I also asked Juliano during our talk if their economic situation had changed
after he started working in the US. Juliano replied that it was very different,
since what he would make in four days in Nicaragua only took an hour in the
US. Thanks to this, they had been able to improve the family’s living
conditions, and he could also help others.
Juliano:
”Of course…it’s much better [súper mejor] here. We rent a house, my son is
studying, my wife too… It’s different, I live well there, I can save money to be
able to come home for visits… […] My son’s school costs US$20 a month. The
education is much better. If I’d been here, he wouldn’t have been able to go
there. And apart from the studies… I’ve become independent [yo me
independice], I own everything I have. This has helped me a lot. But also, more
182
than anything…when you’re there, the economic conditions improve, you help
a lot of people. Because, since there’s extreme poverty here, illness, things like
that… Being there, I talk to them – ‘How is he’, I ask ‘Do you have any
problems or anything’… I help them and send them money. To my sisters,
they’re all older than me, they all have children and all… But, my brother and
I always help them a lot, in this way…it’s much better…yes, you have the
possibility to help…”
Juliano had on several occasions also helped his extended family in Nicaragua
with expenses in relation to illness, as well as when relatives had died. He also
said he and his brother and father sent money for medicine, which his sister,
who worked at a pharmacy in Managua, could send to León when someone
needed it, which they later repaid using the remittances.
Juliano:
“Yes, illness, also misfortune, death in our family, a cousin and an uncle. We
were there [in the US], and sent money here. Also, another [uncle]… My
father, my brother and I, we sent US$1,000 here, so that they would help him
with his illness. If we’d been here, what could we have done?” <<C: What did
you send the money for?>> “To go to the doctor, for medical consultations,
we sent him to a private clinic, not a public hospital, it’s better, there’s better
medical attention [hay más atención]. You know that in a public hospital
there’s more people, and since we have the possibility to do it [send him to the
private clinic], we do it. When there are things like that, we send money. […]
But, thank God, my sister is the director of a pharmacy in Managua… Look,
whatever medicine, we just call her, ‘Look, take out this medicine and we’ll
pay for it’…”
Juliano and Cindy’s living conditions had thus greatly improved thanks to
Juliano’s migrant work and the remittances he sent. They had been able to
move out of their parents’ places to a rented house, which they had equipped
with everything they needed. Cindy had resumed her studies, and their son
had started attending a good, private school. The higher income made it
possible for them to choose a better school than would otherwise have been
possible. And, thanks to Juliano’s remittances, other family members and
friends had also received a great deal of help. For example, some had been
able to attend private care facilities, which according to Juliano were better
than the public health care; the family could thus choose better care than what
would have been possible without these additional resources. This highlights
the socio-economic inequities in the access to and use of health care services
in Nicaragua, pointed out by Angel-Urdinola, Cortez and Tanabe (2008). In
Nicaragua, individuals belonging to households with higher incomes, as well
as higher educational level, seek and receive treatment more often, and the
richer tend to use services of higher quality (private clinics, INSS services)
while the poorer more commonly use public facilities (health care centres,
health posts) that are free of charge but often of poor quality. In relation to
household expenditures on health, non-poor households spend more on
183
insurance, tests and hospitalization – thus items related to better quality
services – while poor households spend more on medications. Juliano’s family
had also been able to receive medication thanks to the remittances. The help
from the sister who worked at a pharmacy in Managua had also been
important for the family’s health care needs. My interpretation of what
Juliano narrates is that acts of care are carried out at a distance,
transregionally and transnationally – hence, translocally – and that these acts
are crucial to the access to (quality) health care and medicine.
Maribel, who had worked in Costa Rica for several years to support herself
and her two children, sent home most of what she earned – about US$200 per
month150 – to her mother, who took care of her children. Sometimes the
money was also used for her mother’s expenses, and for health care costs.
Maribel:
“Since I’m alone, I sent US$100 every fortnight for my two children.” <<C:
What was the money used for?>> “To pay for school fees, food…and help for
my mother…for whatever extra, for whatever my children needed. They called
me on the phone, ‘She’s sick’. Sometimes I didn’t have enough, I was
desperate, how shall I pay for the housing?”
Maribel thus sent a rather large amount of money back home, sometimes even
more than she could afford. Many studies refer to women often sending more
remittances than men relative to their incomes; however, as there are highly
varied results this might not be the case. Nonetheless, gender certainly has a
role to play in remittance patterns (King & Vullnetari 2010).
For other interviewees – like Fernando, Gloria, Carmen and Cesar –
remittances served as a supplement to other incomes, but were still an
important part of the families’ livelihoods. Fernando explained, upon my
question of whether his wife in Spain sends him any money:
Fernando:
“Yes, this is the idea, it’s the idea…she sends. We save money [hacemos una
economia]…1,000 or 1,100 dollars…to pay off the debt, a bit for food… And,
sometimes she helps her sons [the older ones].”
Carmen’s husband sent money from the US that was used to pay for food, the
girls’ school expenses and his niece’s education, as well as agricultural workers
who helped Carmen’s father-in-law in the field. Carmen also mentioned that
the remittances were sometimes used for health care expenses.
150 In comparison, one source states that 44% of Nicaraguans in Costa Rica remit an average of US$70 per
month (and that the monthly average from Nicaraguans in the US is US$150) (Jennings & Clarke 2005, with
reference to Orozco 2003).
184
Carmen:
“[We use the money] for workers, and sometimes…when the girls are sick, we
have to go to the health care centre…we spend it on that…for whatever. And,
for school, because they [their daughters] don’t go to school if they don’t have
some money [1-2 pesos] with them … And to feed us too…buy food…rice and
beans, oil….meat…everything is expensive…”
Joanna said that while she was living in Guatemala she had sent smaller
amounts of money, as well as goods, to her mother and sisters – as a way to
improve their living conditions a bit.
Joanna:
“I sent her [her mother] money, not any large amounts, but yes I sent her
money.” <<C: What did she use the money for?>> “I sent it to her for
whatever she wanted to buy. Sometimes perhaps I didn’t send her money, but
I sent her little things, like that. Like an iron, a television, stuff like that, like
presents. To my sisters I sent clothes, other things, like what they needed the
most here.”
Cesar did his best to find the best paid jobs when he was working abroad (as
well as in Nicaragua), in order to be able to send his wife and daughters as
much money as possible. For example, when he was working in Costa Rica he
sent a total of US$100 per month to his wife and his mother. He kept US$50
for his own living costs and for making phone calls back home. He tried to be
as economical as possible, for instance by paying a girl to make his food
instead of buying groceries or ready-made food himself. When Cesar
eventually returned to Nicaragua, after a year, the family had managed to
build up some savings, but not enough to buy the car Cesar used as a taxi or
the taxi sign (mentioned earlier). Part of the savings had to be spent on other
things as well; on medical expenses, because his daughters were sick, and on
house repairs.
Cesar:
“When I was in Costa Rica, I managed to save up part of the money [for the
car]. […] But not enough to buy it at once.” <<C: Did you save money for other
things as well, not only for the car?>> “Yes, exactly. But then when I returned
to Nicaragua, my daughters were sick. So, well, I had to use the savings to give
to them and to buy supplies. Because you know, when you come home from
another country, when you come from another country to see your family, you
have to buy them things, like clothes, shoes, food…for a while you’re good. And
also, our bathroom was, well…how should I say…it was like a bucket with
water pouring out… So, I told my mother that we have to find another way, we
have to make a proper bathroom, with a shower and everything… So that it’s
more presentable [para que sea más presentable], I told her. I spent money
on that.”
Cesar had thus saved a great deal of money during his time away, but could
not invest it as he wished when he returned since more urgent needs (e.g.
health problems) demanded resources. His intentions to make investments in
185
order to improve their living conditions from a long-term perspective were
thus thwarted because of the surrounding context of poverty, and the lacking
health care system in Nicaragua. In his quote, Cesar also mentions that he had
to spend money on presents upon his return. His narration thus also
highlights the importance of gift exchanges within family networks.
As mentioned, the survey study showed that remittances were also sent within
the borders of Nicaragua; what I call “internal” remittances. This process was
highlighted in the interviews too. For example, Rosa regularly sent money to
her mother, who lived in the countryside with Rosa’s children a day’s trip from
Rosa’s workplace, for the children’s support.
Sometimes, internal remittances served more as gifts. For example, Marta
mentioned that she always brought something with her when she visited her
family at her birthplace, and that her sister did the same when visiting León.
Marta:
“When I go there [to her birthplace], I bring food that I share with them [her
relatives]. But I don’t send them any money, no. […] And my sister, when she
comes, she brings a chicken or something…she brings me something… […]
Maybe…if…if my children lived there, and I worked here, I’d have to send
them [money]…that’s logical [es lógico]…but since I have them here…”
Marta made an interesting observation at the end of this quote. Since her
children lived close by, it was not a must for her to send money back home. I
interpret this as Marta only considering it an obligation to send money
remittances to her closest significant others, for instance her children. This
may very well be the case if you do not have much money yourself, because of
the socio-economic conditions. Still, the general discourse I experienced
during my time in Nicaragua was that it often was expected that you would
contribute and share what you have with others if you had the possibility to
do so, particularly at funerals.
The situation for people with little financial resources is further highlighted in
Mercedes’ story. Mercedes always tried to bring her mother (who in reality
was her aunt) “a little something” when she visited her. She nevertheless could
not give her much, and sometimes could only bring food. Since her mother
was very poor, she could not help Mercedes in return, besides giving her little
gifts (e.g. fruit and vegetables) when Mercedes and her family visited during
harvesting season.
Mercedes:
“I go [to visit my mother] when, when I’ve saved up a little money. I go to see
her. The last time I went was for Mother’s Day, a fortnight ago.” <<C: Can you
help her in any way?>> “Yes, I can…or…” <<C: Like send her money?>> “It’s
hard, it’s very hard [Me cuesta, me cuesta mucho], because… Imagine: I have
186
six children […] well, the cost we have for the household… When we have some
money we go to her, we bring her a little something. Sometimes we bring food,
sometimes we bring, eh… Well, at least two weeks ago I went and bought some
vegetables, and we made a soup there, very nice [muy rica], and we gave her
a little money [sus realitos].” <<C: And your mother, can she help you too?>>
“No, she’s very poor.” <<C: Not even fruit or something…?>> “Of course,
when there’s fruit, we bring home fruit, sometimes when she has corn, she
gives me corn. So, well, I get my gifts [mi regalo], but that she helps me – no,
but she’s very poor, very poor…”
Mercedes’ narrative thus shows how poverty can be a constraint to helping
others, even if people want to help. In relation to the survey findings, this may
explain why the share who provided help to others was higher in León than
Cuatro Santos, where poverty is much more widespread (see Table 11, p. 175).
Internal remittances were also sometimes important in acute situations,
which the interview with Marta clearly showed. Several years prior to our
interview she had suffered from stomach cancer, for which she needed
medical examinations and surgery. The costs for the treatment would be about
C$10,000, which Marta had no possibility to pay, since her salary as a maid
was very low. She asked for help from her employer, who then went to the
hospital with her. In the quote below, Marta further explains how the situation
was solved with the help of many different actors.
Marta:
“[W]e talked to the hospital director, and to the vice-director, and he gave me
a paper, an order that they would hospitalize me. And, then they operated on
me…” <<C: For free?>> “For free. I only had to pay for the examinations,
right. A cousin who lives in [her birthplace] sent me money for the ultrasound,
my other cousin here gave me C$400… And at the hospital they made various
exams, and they cost me almost C$2,000, in all… And then [her employer]
came and asked what I needed, and I said, I need exams that cost almost
C$2,000… So, she asked her tenants [two Dutch women] and they helped me.
They helped me, thank God.”
Marta thus experienced the effects of Nicaragua’s non-inclusive health care
system. Even though the acute surgery in itself was free – after Marta and her
employer had convinced the hospital managers that Marta was too poor to
afford the high cost it actually entailed – she had to pay for the necessary
examinations out of her own pocket. In this situation it was very clear how
important her social network was, since Marta could not afford to pay for the
exams either. Financial help came from various people in different places –
cousins, her employer, foreign tenants of her employer. Marta’s care was thus
managed in a translocal support network rather than as part of a “social
citizenship”, which could have entitled Marta to care regardless of her
economic resources.
187
Hence, the interviews showed that remittances were an important type of help
for getting by in life, sometimes an important source of income, and often part
of the strategies for making a living; thus a central aspect of the practice of
mobile livelihoods. For some, remittances were what had motivated migration
events in the first place. The importance of the financial remittances in
relation to the household economy varied, however. Remittances were sent
both within the borders of Nicaragua and from abroad. According to the
interviews, the remittances were used for a variety of reasons – to pay for daily
living expenses (e.g. housing, education, health care and medicine) and to
improve living conditions (in the short and long run), for example through
improving housing conditions, paying off debt, for investments, and for
savings. Some of the interviewees also mentioned receiving or sending goods,
such as clothes or electronic devices. Remittances were sometimes very
important in times of health needs; thus, care could be seen as being
exchanged in translocal social spaces, when the social rights of citizenship do
not match people’s health care needs.
Who receives remittances? Results of the survey study
The findings of both the qualitative and quantitative analysis were that
remittances were part of many study participants’ lives, and were often used
for health purposes. These findings are consistent with previous studies on
remittance-receiving households, and the use of remittances in Nicaragua
(e.g. Morales & Castro 2002; Fajnzylber & López 2007). The question is who
receives remittances, and what role they play in health, including when
demographic and socio-economic factors are controlled for in a larger
population. As previously stated, remittances can be seen as a type of social
support (i.e. instrumental/material support) that is exchanged within social
networks. Research has shown that interrelational social support and strong
social ties can help an individual cope with negative life events and stress
(Thoits 1995; and Turner 2004; with reference to Berkman & Syme 1979, and
Dohrenwend & Dohrenwend 1981). The reason for this, according to social
capital theory, is that people’s social investments (i.e. engagement in social
relations) create social integration and social inclusion, which have been
proven to enhance population health (Turner 2004; Seeman 1996). As there
is evidence that social support is important for health, in this study I have
looked at the issue of remittances (as an indicator of social support), and
investigated whether there is any association between those in the study
population who receive remittances, and indicators of health. Furthermore, as
previous studies have shown that more affluent households make up a
relatively high share of the remittance-receiving households in Nicaragua
(Fajnzylber & López 2007; Jennings & Clarke 2005), I also wanted to examine
188
whether there were any socio-economic differences in remittance-receiving in
this study’s population, or other differences according to aspects such as
gender, age, and migration networks.
Binary logistic regression analysis was performed on the survey data for these
purposes. The aim of this analysis was, thus, to gain a fuller understanding of
who received remittances, and if any associations could be found between
remittance-receiving and health status. The dependent variable used in the
analysis was “being a remittance-receiver” – in short, “remittance-receiver”
(with the values “yes” for those who had received remittances, and “no” for
those who had not; based on Question 16 in Survey 2008). The independent
variables were: sex (female/male); age (continuous)151; poverty (poor/nonpoor)152; education (low-educated/medium-high-educated)153; occupation
(skilled worker/other)154; migration categories: Non-mover (yes/no), Leftbehind (yes/no), In-migrant (yes/no) (based on HDSS data, and categorized
in our sample process; see Chapter 3); health categories: Healthy (yes/no),
Chronic ill (yes/no), Other ill (yes/no) (based on Question 10, Survey
2008)155; self-rated physical health (good/bad) and self-rated mental health
(good/bad) (based on Questions 8 & 9, Survey 2008)156; social insurance
(yes/no) (Question 13, Survey 2008); perceived economic support and
perceived emotional support (yes/no) (Questions 14 & 15, Survey 2008);
migration/translocal network: if the person had family members in other
places (yes/no) (Question 6, Survey 2008), size of migration network
151 Sex and age were mostly used as control variables rather than explanatory variables.
152 The value “poor” included those categorized as poor and extremely poor, and “non-poor” those categorized
as non-poor, based on the poverty index used in the HDSS (see Chapter 3). Of the study population, 68% were
poor (of whom 4.4% were extremely poor), while 32% were non-poor (weighted percentages).
153 Based on the HDSS data on educational levels, “low-educated” included those with primary school as their
highest attained education (including illiterate and just literate individuals); and “medium/high-educated”
included those with secondary school or college/university as their highest attained education. Of the study
population, 63% were low-educated (of whom 16% had no or very low education), and 37% were medium/higheducated (of whom 7% were high-educated) (weighted percentages).
154 Based on the HDSS data on occupations, and the International Standard Classification of Occupations
(ISCO-08) (see ILO 2012), “skilled worker” included those occupied in jobs at the second to fourth skill levels
(skilled, highly skilled and very highly skilled), for example drivers, teachers, and professionals; and “other
occupation” included those occupied in jobs at the first skill level (non-skilled workers, e.g. street vendors) as
well as housewives, students, and the non-economically active (unemployed, retired, disabled). Of the study
population, skilled workers amounted to 20% (of whom 12% were skilled, 7% highly skilled, and 1.5% very
highly skilled) (weighted percentages). Of those with other occupations most were housewives and non-skilled
workers (30-31% each); the rest were students (9%), working in “other” jobs (4%), non-economically active, i.e.
retired or disabled (3%), or unemployed (2%).
155 The illnesses reported in Question 10 were categorized as “chronic” and “other” (including acute, mental
and various other health problems), based on the International Classification of Diseases, ICD-10, available at:
http://apps.who.int/classifications/icd10/browse/2010/en.
156 The values for both physical and mental self-rated health were categorized accordingly: “good” for the
options excellent, very good and good; and “bad” for the options bad and very bad (see Questions 8a and 9a,
Survey 2008).
189
(few/many)157, range of migration network (in Nicaragua/abroad), location of
transnational migrants in the family (the US/other country) (Question 7,
Survey 2008); and immigration status of emigrated relatives
(“legal”/undocumented) (Question 20, Survey 2008).
A key question in research on remittances is the importance and impact of
remittances for households in different socio-economic positions and
individuals by age and gender; i.e. how remittances are distributed in the
population. Hence, one aim here was to examine the extent to which
remittance receiving was associated with gender, age and various indicators
of socio-economic position158. The results from the regression analysis
indicate that it is more likely for older people to receive remittances, while no
significant differences between men and women were found (Table 13, next
page). Compared to previous studies that point out poverty levels as
influencing remittance-receiving patterns in Nicaragua – according to
Fajnzylber and López (2007) richer households more often receive
remittances, and according to Jennings and Clarke (2005) remittancerecipients are more often low- or middle-class, but not extremely poor – no
significant associations could be found in the survey material between
remittance-receiving and socio-economic status measured in terms of poverty
and educational attainment. However, the regression revealed a significant
negative association between being a skilled worker and receiving
remittances. The skilled workers had a stronger socio-economic position than
those in other occupations (they were more often non-poor and welleducated). One interpretation of the regression result is thus that the people
in the highest socio-economic positions in the two study settings were less
likely to receive remittances. However, this group was relatively small
(comprising just 20% of the study population; see Footnote 154 above), which
can explain why overall poverty and educational levels did not significantly
affect the probability to receive remittances. Furthermore, in Nicaragua, the
most socio-economically advantaged residents do not commonly live in León
and Cuatro Santos, which also can explain why other studies, conducted on
the national level or in other areas, point out that remittance receiving is
affected by poverty and educational levels (i.e. that the richer or low/middle
class, but not the extremely poor, households more often receive remittances).
Another interpretation of the regression results is that the skilled workers in
157 As mentioned in Footnote 133, respondents with zero to four family members in other places were
categorized as having “few” relatives in other places (also called “small migration network”), while those with
five or more relatives in other places were categorized as having “many” relatives in other places (“large
migration network”).
158 In the HDSS the data about education and occupation are individual, while the level of poverty is a
household indicator. Although the question about remittances in our survey was asked to the sampled
individual, it is possible that the answer gives a picture of the total remittances to the household.
190
the study settings due to more stable incomes manage better without external
remittances.
Table 13: Logistic regression: “Remittance-receiver”
B
SE
Constant
-2.325***
0.463
Woman
0.147
0.245
Age
0.026***
0.007
Skilled worker
-1.189***
0.332
Low-educated
0.117
0.312
Poor
-0.177
0.290
N (unweighted cases)
Pseudo R square (Nagelkerke)
1282
0.074
*** = p<0.001, ** p<0.01, * p< 0.05
I also investigated whether there were any associations between those who
received remittances and the characteristics of migration/translocal
networks. No significant associations could be found between remittancereceivers and the size of migration/translocal networks (few or many relatives
living in other places; see Footnote 157) (not shown here). However, a positive
significant association was found between remittance-receivers and those who
had family members in the US, in contrast to in other countries (Table 14).
Table 14: Logistic regression: “Remittance-receiver”
Constant
Woman
B
SE
-2.107***
0.378
0.111
0.261
0.025**
0.008
Relatives in the US
0.533*
0.268
N (unweighted cases)
Pseudo R square (Nagelkerke)
852
0.070
Age
*** = p<0.001, ** p<0.01, * p< 0.05
Hence, according to our survey, family members of Nicaraguans residing in
the US were more likely to receive remittances. This is in line with previous
findings; according to the UNDP (2009), two-thirds (66%) of the remittances
that enter Nicaragua are sent from North America (see Chapter 4). When
occupation (skilled worker/other occupation) was added to the analysis this
association remained significant. Those with relatives in the US thus received
more remittances, while skilled workers received fewer.
191
Based on the idea that remittances – as an indicator of social support – may
be important for health, I also investigated whether there was any association
between those in the study population who received remittances and
indicators of health, when socio-economic factors were controlled for. The
regression analysis showed no association between remittance-receiving and
different indicators of health status. For example, as seen in Table 15, there
was no significant relation between those who were healthy (i.e. those who
reported no illness in Question 10 of the survey) and those who received
remittances.
Table 15: Logistic regression: “Remittance-receiver”
B
SE
Constant
-2.255***
0.373
Woman
0.217
0.233
0.020**
0.007
Healthy
-0.235
0.239
N (unweighted cases)
Pseudo R square (Nagelkerke)
1383
0.041
Age
*** = p<0.001, ** p<0.01, * p< 0.05
Moreover, as seen in Table 16, there was no significant association between
self-rated physical health (Question 8a) and remittance-receivers. The
analysis of self-rated mental health (Question 9a) showed the same result.
There was thus no difference between those who rated their health as good
and those who rated it as bad in relation to remittance-receiving.
Table 16: Logistic regression: “Remittance-receiver”
B
SE
Constant
-2.331***
0.477
Woman
0.230
0.232
0.021**
0.008
Good self-rated physical health
-0.115
0.274
N (unweighted cases)
Pseudo R square (Nagelkerke)
1382
0.039
Age
*** = p<0.001, ** p<0.01, * p< 0.05
Hence, according to the regression analysis, health status did not seem to
influence the reception of remittances. This is somewhat contradictory to the
previously presented findings of the survey study, as well as to the qualitative
findings, which showed that remittances are often sent and used for health
purposes. This inconsistency might be explained by the fact that the major
motive for sending remittances as well as the major use of them was in fact
192
connected to daily expenses (such as housing and food), rather than health.
Or, it could be that remittances were not sent to aid the respondent’s health
problems but rather those of others (e.g. family members).
However, the regressions did show a strong positive association between those
who received remittances and those who received help when they were sick
(Table 17). Remittance-receivers were thus more likely to also receive help
during illness.
Table 17: Logistic regression “Remittance-receiver”
B
SE
Constant
-3.034***
0.480
Woman
0.025
0.332
Age
0.029***
0.009
Received help when sick
1.141***
0.326
N (unweighted cases)
Pseudo R square (Nagelkerke)
842
0.139
*** = p<0.001, ** p<0.01, * p< 0.05
Thus, in general, health status did not have an effect on remittance-receiving.
However, in the event of illness, those who usually received remittances were
more likely to also do so during the illness period. This is an important finding,
since we know from the survey and the in-depth interviews, as well as from
previous research, that remittances are often used to pay for both health care
and medicine in Nicaragua due to the country’s non-inclusive health care
system. Those who receive remittances during the illness period may thus
have better access to health care than others, which may improve their health
situation.
In sum, the survey study showed that remittance-receivers were more likely
to be older and either non-skilled workers, housewives, students, or noneconomically active. These groups are perhaps in a more disadvantaged
economic situation than younger individuals and skilled workers, and
therefore
receive
more
remittances.
Moreover,
regarding
migration/translocal networks, the results confirmed findings in previous
studies that remittances are often sent from the US. Additionally, the
regressions showed that those who reported health problems and received
help during the illness period also received high levels of remittances, which
may enhance these individuals’ possibilities to tackle the situation of illhealth, and possibly receive better treatment (e.g. medicine and private health
care).
193
Summary and conclusions
In this chapter I have shown that contemporary migration in Nicaragua is
often related to the troubles of making a living. I argue that Nicaraguans
practise so-called mobile livelihoods, in which mobility is used as a strategy
for making a living in order to improve life and “move forward” (seguir
adelante). The mobile livelihoods people practised involved both different
places in Nicaragua and places abroad, thus a translocal type of mobile
livelihood aptly analysed within the translocal geographies framework. Both
the in-depth interviews and the survey study confirmed previous research on
Nicaraguan migration patterns, for example that internal moves often flow
from rural to urban areas, and that international moves most often lead to
either Costa Rica or the US. Migrant networks in these countries influence
new migrants to come, which upholds these transnational migration systems
since relations between significant others still continue, albeit in new forms,
i.e. that of transnational social spaces (translocal social spaces if the stretchedout social relations, due to migration, take place in both a local and a
transnational context).
The qualitative interviews clearly showed the complexity of migration
motives. Even though economic motives predominated, other reasons for
migration could also be involved in the decision-making process. Social
reasons were very common in the survey, as well as in the in-depth interviews.
For some interviewees, migration/translocal networks were highly influential
on the decision to move, while for others the lack of a supporting social
network at home had necessitated migration. Social networks and social
relations were thus important in the migration process. Gender ideologies,
particularly Nicaraguan parenting practices (especially mothering), could also
be in play in migration decisions. Some women moved in order to support and
take care of their children, or stayed/returned due to worry over their
children’s well-being. Health issues were also integral in the decision to
migrate, stay or return. Even though only 2% of the survey respondents
particularly mentioned health as a reason for migrating, many of the
interviewees talked either directly or indirectly about health issues. This is an
interesting finding, and highlights the benefit of mixing qualitative and
quantitative methods in the same study. The qualitative study showed that a
particular health problem could influence migration decisions (cf. health
selectivity in migration), and that women’s health (e.g. exposure to abuse,
reproductive health) was affected by, and affected, migration events.
Emotions could also be highly in play in migration decisions. The chapter
furthermore pointed out the complexity of migration-health relations in
people’s lives, the multitude of ways health can be affected by migration
events, and how migration can be influenced by health concerns. As health is
194
integral in all our actions, this is perhaps not surprising. People’s vulnerability
and suffering in relation to Nicaragua’s widespread poverty, insecure
livelihoods, and unpredictable nature conditions were underlying reasons for
migration for some. Due to historical and contemporary socio-economic
transformations, a large part of the Nicaraguan population indeed suffers
from a multitude of vulnerabilities (a structure of vulnerability).
The chapter highlighted different ways of coping with hardships. The
exchanges of help within social networks, as well as the aid provided by
international organizations, was very important for many for getting by
(surviving). The survey study showed that a fifth received and/or provided
help; primarily in the form of money, but also as utilities or food. Help was
usually received from someone who lived abroad, though people in other
places within Nicaragua also provided help, which shows that both local and
international (i.e. translocal) networks were important. Those who had social
insurance numbered fewer than those who received/provided help, which
indicates that the help exchanged within social networks may be of crucial
importance in times of illness, since those lacking social insurance often have
to invest more private money in health care and medicine. I argued that
remittances can be seen as a type of social support (i.e. instrumental support)
that is exchanged within translocal social networks, and that may impact
health. The survey study showed that the share of households receiving money
remittances was roughly similar to what has been reported elsewhere, and that
these remittances were primarily used for daily consumption, health and
education. The results did not show that poverty or education influenced who
received remittances, but nevertheless that occupation played a role.
Housewives and non-skilled workers (as well as students, and the unemployed
or non-economically active) more often received remittances in contrast to
skilled workers, which indicates that these groups are in a less advantageous
economic situation than the skilled workers. An important finding was that
almost a quarter of the remittances were used for health purposes, and that
the remittances received during periods of illness were predominantly used to
pay for medicine and private health care, which together shows that
Nicaraguans invest a great deal private resources in health care and medicine,
and that remittances can be important for improving people’s health situation.
The in-depth interviews poignantly showed how crucial remittances can be at
times of acute health crisis, and how the access to health care and medicine
can be greatly improved. The reason why so much money was used for health
purposes is related to the fact that Nicaragua is characterized by a noninclusive health care system, in which people have to invest private resources
to be able to receive the necessary care and medicine (see Chapter 4).
However, it can also be a sign of over-use of medication as a consequence of
the process of medical globalization. Nonetheless, due to the harsh economic
195
situation and the exclusionary social regime in Nicaragua, the resources from
migration (i.e. remittances) have become a way for many Nicaraguans to
compensate for the country’s lacking social sector in Nicaragua (Fouratt
2014). The question is whether Nicaraguans’ right to health – as stipulated by
law – is met under these conditions, i.e. whether the Nicaraguan people are
guaranteed their social rights of citizenship. Regarding the development
potentials of remittances, this chapter has shown that they are an important
part of many families’ livelihoods, and often used to pay for food, clothes,
housing, education, and health care. Even though some regard these kinds of
investments as “unproductive”, they are important since these areas (i.e.
nutrition, education, health, etc.) are crucial for sustaining development (e.g.
Ashtana 2009; Ruger 2003). However, remittances do not reach all
Nicaraguans equally; especially not the poorest. Furthermore, there are many
negative aspects of migration that need to be taken into account when
discussing the development effects of migration and remittances, for example
family separation, as well as risks, exploitation and “othering” during the
migration experience. These issues will be the focus of the next two chapters.
196
CHAPTER SIX
Health on the move
Introduction
This chapter is concerned with the direct and indirect, positive and negative,
health consequences of migration for the migrants who participated in this
study. The chapter is related to the third research question of the thesis (“In
what ways does migration affect men’s and women’s lives and health
situations in the different places and during the different phases involved in
the migration process?”); and more specifically to one part of this question,
namely: How do different kinds of migration experiences affect the migrant
(e.g. socially, economically, healthwise, and emotionally)? The chapter will,
for example, provide answers to in what ways the migrants’ health and their
access to health care and medicine are affected during the migration process,
and how the migrants cope with the changes and difficulties they encounter
during moves.
Through focusing on the migrant, this chapter investigates the first
connection in the conceptualization of migration-health relations (MH), i.e.
the ways migration affects health. It thus relates to research on migrant
health, for example the stresses of migration and life after migration. The
chapter takes into account different phases in the migration process and
focuses primarily on the conditions during travel, at the destination, and after
return in the place of origin. In the chapter I discuss processes of “othering”
and migrants’ vulnerability, precariousness, and suffering. I also analyse
different strategies for coping that migrants develop during the migration
process. Finally, I examine how changes in the access to education through
migration can indirectly affect migrant health.
The chapter uses mainly qualitative but also some quantitative data, and
follows migrants along their path – during the travel, in the new place and
after their return home.
197
The journey
The interviewees described the journey from origin to destination very
differently, depending on the individual context. The most important factor
determining the travel experiences of the international migrants was whether
or not the person had legal immigration status. The accounts of migrants in
more dangerous situations during the journey thus mostly concerned those
who had crossed country borders undocumented. However, some of the
internal migrants had also gone through tough times in order to reach their
destination; particularly Ana, whose story is presented below. Her experiences
of migration might perhaps be an exception, in relation to the other
interviewees who had migrated within Nicaragua; however, I believe it is
important to also acknowledge the dangers that internal migrants can
encounter.
Passing through the jungle
Ana, who was 22 years old and worked as a maid in León, came from a remote,
rural area far from León where she was born and raised. She had never gone
to school; according to her mother because of the risks it might entail, but
according to Ana because her mother and brothers wanted her to be kept hard.
Ana had, furthermore, been sexually abused by her father, which resulted in a
pregnancy, and was subsequently kept hidden away from the village to give
birth to her child. After this, when she was around 15 years old, she moved
away from home because her family blamed her for what had happened, and
because she did no longer felt like part of the family. In this difficult situation
Ana decided to head for León, the closest town she knew of. Her journey from
her home community went through the jungle. She started off on her journey
all alone, but shortly thereafter met a nice young man who offered her help.
The two stopped off together, for a period of a year, to work on coffee and bean
plantations, in order to make money for the continued travel. In the following
quote Ana describes her journey, and the difficulties and dangers she went
through during her migration.
Ana:
“I left home, I didn’t know anyone, I’d never gone to the city before, so… Then
I met a friend, he said ‘Look, I’ll help you’… ‘Alright’, I said, ‘I trust you, and
I’ve never been in the city before.’ ‘Don’t worry, I’ll bring you to my family’ [he
said]. We worked for a period there. Not here in León, but still in the
mountains… We cut coffee, a season of coffee [una temporada de café], then
we harvested beans, we sold it… We were there like a year, there in the
mountains. When we got here, we had to pass the Rio Hondo… We swam
across the Rio Hondo… […] [M]igrating, it’s very…difficult, because one…risks
everything, right, because one doesn’t know if… You go with the objective to
work, but on the road [en el camino] there are a lot of obstacles you go
198
through…problems…so that sometimes you don’t…you don’t make it to the
goal you have, right. So…it’s very dangerous, right… When I got here [to León]
I didn’t get here in two days like I wanted to, I couldn’t come…the car broke
down…and so after that… I was left without money to get here…so I had to
work… […] And…this work is very dangerous, there are snakes [culebras]
where you walk to cut the coffee, so it’s dangerous… So…I felt…sometimes I
felt, I said to myself ‘I won’t make it to the city’…”
Ana was thus in a rather vulnerable situation during her travel to León, for she
was all alone, knew little about the world outside her home community, and
was obliged to confide in the young man she met on her way. Luckily, he was
kind and helpful. She also had to work on the plantations, which is most often
a hard, dangerous, and precarious type of work. She mentioned, for example,
that she was not given sufficient food during her time at the plantations, and
that there were a great deal of poisonous snakes and other dangerous animals
she had to watch out for. She also had to cross the river, which she portrays as
a very tough and dangerous effort. Ana sums up her experience of migration
as a difficult, risky and dangerous endeavour, filled with uncertainties as to
whether or not you will make it to your destination. Eventually, Ana reached
a town to the north of León where her friend had relatives who helped her find
work as a housekeeper. After seven years she eventually moved to León, where
she lived at the time of the interview.
Ana’s story highlights several issues with relevance for the thesis’ analysis of
migration-health relations: first, the social aspects of vulnerability,
exemplified by her vulnerability within the household and the negative
emotional experiences (the suffering) this entailed, which was what motivated
her to migrate; second, the role of human and social capital, as Ana, who had
not received an education, had little knowledge about the surrounding world
and was therefore “at the mercy” of support from people around her; third,
the precariousness of work (Standing 2014), exemplified in Ana’s story by
temporary/seasonal agricultural contracts and housekeeping, which are both
jobs in which the employee has few rights in relation to the employer
(precariousness will be discussed more, later in the chapter) – luckily, Ana
had only good experiences of those she had worked for as a live-in maid, but
nevertheless she made very little money; and fourth, the dangerous crossing
of the river (which can be regarded as an internal border), which Ana had to
do in order to continue her journey.
“Illegal” border crossings
Borders – particularly international ones between one independent nation
and another – do still have a role to play in today’s “mobile” world. Border
thinking is indeed fundamental to the human experience; as Shahram
199
Khosravi (2011: 2) writes, “[t]he national order of things usually passes as the
normal or natural order of things” (italics in original). In this line of thinking,
border crossing can thus be seen as breaking the “normal” order; in Khosravi’s
words: “[b]order transgressors break the link between ‘nativity’ and
nationality and bring the nation-state system into crisis” (ibid.). Moreover,
borders also create differences between people in migration flows. As YuvalDavis and Stoetzler (2002: 330-331) explain, boundaries and borders are
“modes of delineating identities” that separate the world into “us” and “them”:
those who belong and those who do not (see also e.g. Newman 2003). Borders,
and border politics, are thus pivotal when discussing international migration,
since they regulate who can and cannot migrate; “whose bodies belong where”
(Silvey 2006). Moreover, when communities are defined externally by
boundaries and borders, the question of citizenship comes to be of crucial
importance, as the ultimate proof of belonging to a community (Yuval-Davis
e.g. 1997, 2007), as well as concerning citizens’ rights.
Borders are often dangerous settings. “Illegal” border crossings often put
migrants, particularly females, in a vulnerable situation. As Khosravi (2011:
27) writes, “[a]n ’illegal’ traveller is in a space of lawlessness, outside the
protection of the law”. An “animalization” of border crossers in fact often takes
place, in which human smugglers and their clients are given animal names,
such as coyotes and pollos (chickens) in the Mexican case – which points to
the vulnerability of border crossers (ibid.). Besides difficult strains and
sufferings, migrants also face death during the journey. The Mexico-US
border is especially relevant for this thesis; this is a borderland where
approximately 1,600 individuals died during the years 1993 to 1997 (Eschbach
et al. 1999), and a total of 6,029 individuals died in the southwest border area
in the period 1998 to 2013159 (United States Border Patrol, Internet, accessed
2014-11-30) (see also e.g. Eschbach et al. 2001; Sapkota et al. 2006; Holmes
2013) (lately also in relation to drug trafficking; see e.g. Slack & Whiteford
2011). The Binational Migration Institute (2013) has furthermore shown that
deaths among female migrants have increased, as have those of migrants from
countries other than Mexico, of whom Central Americans make up a large
share160. The literature points to a relation between increased border security
and migrant fatalities (e.g. Eschbach et al. 2003; Cornelius 2001; Orraca
Romano & Corona Villavicencio 2014), partly due to a redistribution of
migratory flows (a “funnel effect”) into more remote and dangerous areas.
Indeed, as Heyman (2014: 123-4) argues, “border enforcement in general, and
159 However, as Orracca Romano and Corona Villavicencio (2014) point out, this number does not include
those who died in Mexico or whose bodies were never recovered, which indicates that the number of deaths at
the border is probably even higher (Alonso 2012 refers to over 7,000 deaths; as quoted in Orracca Romano &
Corona Villavicencio 2014).
160 From 9% of all deaths during the years 2000-2005 to 17% in the period 2006-2012.
200
especially the escalation since 1993, produces illegality effects that endure
across time and space”; effects such as psychological scars, physical or direct
violence (e.g. death and armed robbery), and structural violence (e.g. anxiety,
subordination and exploitation). Moreover, the enforced border politics also
lead to more difficulty travelling back and forth, thus producing “entrapment”
inside the US for the migrant. Besides facing diverse strains and potentially
risking their lives, female undocumented migrants are often also subject to
sexualized violence during the border crossing; by smugglers as well as border
guards (reports of the rape of male migrants are few, yet this probably also
takes place). Khosravi (2011) states that rape at borders is in fact systematic,
and occurs routinely in different borderlands, for example in the US-Mexico
borderland (see e.g. Falcón 2007; and Ruiz Marrujo 2009).
Regarding those in this study who had undertaken international migration, it
was the undocumented migrants who faced a particularly perilous situation
when crossing borders.
Carmen’s husband Gilberto, who had lived in the US for a year at the time of
the interview, had first walked the long way from Nicaragua to Mexico and
then crossed the river at the Mexico-US border in order to get there. Carmen
said she had been very worried about Gilberto during his journey – for one
thing that he would be caught by the police, but especially, as she knew he
planned to cross the river (where many migrants have drowned), she worried
he would die while crossing it.
Carmen:
“Thank God he didn’t get caught. He got there, by praying to God, that God
would let him live… Since he was going to cross the river [al se metir en
agua]… Since so many have drowned, we prayed to God that he wouldn’t
drown…that he would cross…”
Carmen thus experienced her husband’s migration as highly stressful. She
expressed her worry over his well-being, which is understandable since so
many migrants actually die at the Mexico-US border every year. Carmen also
expresses how she prayed for him; her faith in God was thus an important
coping strategy for her.
In the literature migration is regarded as a stressful life event (Helman 2007),
which therefore sets off coping processes. Folkman and Moskowitz (2004)
state that recent decades of coping research have shown that coping is
connected to the regulation of emotion (particularly distress) throughout the
stress process; and that certain coping strategies (so-called escapist coping
strategies) are often detrimental to mental health. Other coping strategies
(e.g. support-seeking and problem-focused) have more mixed effects on
201
health (usually depending on the type of stressor involved). The
understanding of the connections between coping and psychological,
physiological and behavioural outcomes is still not clear, in part because of the
complexities surrounding stress processes. However, the literature on stress
and health indicates that stressors that cause negative emotional feelings such
as anxiety, depression and low self-esteem (or self-identity) can affect physical
health through the onset of biological processes (in the immune system, for
example) that in turn affect disease risk and mortality (see e.g. Williams et al.
2003). Research on emotions, stress and coping has found, for instance, that
positive emotions – for example, love and gratitude – are most often good for
your health, while negative emotions – for instance, hate, sadness and anxiety
– are less good for your health (see, e.g., Chapter 6 in Greco and Stenner
2008).
Hence, emotions are important when individuals try to handle difficult,
stressful situations, as well as for health. In Carmen’s narrative she expresses
that she handled the stressful situation of her husband’s migration in
primarily two ways: by worrying, which as mentioned above is a negative
emotional experience that may influence health negatively, but also by
expressing faith and gratitude. Religion can be used to cope with stress
(Folkman & Moskowitz 2004). That Carmen put her faith in God and prayed,
as well as expressed gratitude over the fact that her husband survived the
journey, may thus, in light of this research, be seen as a way to cope with the
stress she experienced during his migration.
Santos, who was 33 years old and lived in León, also talked in our interview
about the dangerous passage across the river at the Mexico-US border. Santos
had made several attempts to go abroad: twice to the US and once to Costa
Rica. On all three occasions, however, he had been caught by the border police
and deported to Nicaragua. Santos said that during these travels he had
endured situations involving a great deal of physical and mental suffering,
always being at the mercy of the smugglers (coyotes) who made the passage
possible. Santos emphasized in the interview that his migration attempts had
not been easy at all, entailing huge risks and dangerous, utterly painful
situations. He had also suffered greatly from seeing others be humiliated and
hurt; for example, he had witnessed female migrants being sexually abused,
and one of his friends had even died during one of the journeys. The first time
Santos travelled to the US he did so along with four friends. They established
contact with a smuggler in León, who took them to Mexico on foot for a large
sum of money. Having arrived in Mexico, they were handed over to another
smuggler who demanded more money, which they did not have. They
therefore had to make the difficult decision to cross the US border either by
walking through the hot desert, or by crossing the dangerous river. The
202
following is Santos’ account of what he went through in order to enter the US
from Mexico.
Santos:
“[T]he smuggler woke us up at 5 in the morning the next day, and said ‘Here,
shoes, rope [amarrados], water bottle’… We didn’t have breakfast, we didn’t
have breakfast…we walked…many kilometres to get to the border… […] I don’t
know if you know about the Rio Grande, the dangerous river? It’s sad, there
are so many who have crossed it but who have never gotten to the other side…
They call it ‘the river of death’… Well, we had two choices, to cross the river or
go through the desert… So, the five of us, the five of us decided to start
walking… [I]t’s not easy to…it’s hard to reach your goal… Because you see
people who are dehydrated, who are…ehh…bitten by snakes… The sun’s
always up, so…you get a headache, and you have no pills, you don’t have
anything in the desert... We waited there for 15 days, waiting to cross… You
try to find food, you’re thirsty…you have to do something to…survive at that
time… […] [W]e came to a point…to the US. We climbed up into a vehicle…
This is the saddest part…we climbed up into a vehicle, a truck…closed, all
closed up, sad… Children, women…were already there, crying, hungry… And
suddenly we suffered from this… that in the middle of the road, they stopped
the truck, there were the police [migración], they asked if we had documents
[papeles], talked to the driver and he said he was only giving us a ride, he
didn’t know us, he didn’t know who we were… […] They hit us, they threw us
on the floor, they strip-searched us…like an animal… They discriminate you,
they discriminate you and you feel very bad… [W]e were imprisoned for a
month, we were locked up, in a small room, in a cell, they keep you like an
animal, like a dog… They treated us like dogs…”
Santos’ narrative of these events is filled with hardship and suffering, and
serves an appalling example of the direct health consequences of border
politics. Santos suffered physically because of his tough and dangerous
travels, and these tough travelling conditions also caused a great deal of
mental stress – fear and worry. He also suffered because of the border patrol’s
maltreatment. He was physically beaten, and suffered mentally from the
verbal abuse directed against him as an “illegal” immigrant. He also suffered
from witnessing his fellow travellers being hurt and sexually abused. Santos
expressed great sadness when talking about all the difficulties he had gone
through. He also expressed anger towards the border patrol and the Costa
Ricans for not treating him as he deserved to be treated, like a human being.
Instead, he felt he had been treated “like a dog”. Santos’ narrative thus also
highlights the “animalization” of border crossers, which Khosravi (2011)
discusses, and the fact that this process may have psychological consequences
for the migrants involved.
Santos and his friends were released from prison after a month and
transported back to the Mexican border, from which they started walking back
to Nicaragua. On their way, one of his friends died from dehydration. This was
obviously a very painful experience for Santos and his other friends. After a
203
while at home, recuperating, Santos and his friends decided – despite the
suffering they had experienced during their first trip – to make another
attempt to migrate to the US. This time they crossed the Mexican-US border
by train, which is also a very risky adventure, as Santos recounts:
Santos:
“[T]he train passes fast…[…] If you don’t get on at the right time you may cut
off a leg, you can die… It’s not easy to see people trying to get on, falling, losing
their legs…”
Besides the risk of severe injury and even death due to falling off the train, the
train passage is also dangerous because of the gangs (las maras) that patrol
the area (this is also mentioned in the story of José Luis Hernandez, see
Chapter 1, p. 1; as well as portrayed in the film Sin Nombre, mentioned in
Footnote 2).
This time Santos managed to reach Texas, but was caught by the police shortly
thereafter and deported to Nicaragua again. Next, he and some other friends
decided to go to Costa Rica to look for work. They believed it would be an
easier undertaking to go to a neighbouring country which they also knew more
about, but unfortunately it did not go as well as they had expected, as Santos
describes:
Santos:
“[W]e didn’t bring much money, we only had enough for the bus to Rivas, and
from Rivas to the border. We wanted to cross behind [the check point], we
looked for a smuggler [mochila] who would help us, we only had C$300…
And…we got robbed… We continued walking with the smuggler, hungry… We
got to Costa Rica… […] And, we were in a house with other people, and the
saddest part was when they ate, and we only watched, we didn’t have anything
to eat… I didn’t eat for three days […] In Costa Rica, we didn’t even last a
week… […] We suffered a lot, a lot of things… […] Then the police [migración]
caught us, it was difficult…because they took us in, we were fined, they
demanded money… They hit us, we were imprisoned. Then they took us close
to the border and said to start walking… […] The Costa Ricans [los ticos] don’t
want you there, they hit you, they hate you, they look at you in a terrible way…
They don’t want you to cross their borders… We suffered crossing the
border…”
From León, Santos and his friends thus went to Rivas, which is situated close
to the Costa Rican border. This borderland is not guarded as well as the one
between Mexico and the US; however, you are not allowed to cross unless you
have a valid passport and visa (which for some is too expensive to acquire).
Therefore, people also cross the border unauthorized, often at night, and at
more distant locations far from the checkpoints. Santos and his friends hired
a smuggler (mochila) who could guide them and take them securely over the
border and into Costa Rica. In relation to the new immigration policy in Costa
204
Rica (in place during the fieldwork period), border security had become
intensified in order to stop “illegal” immigration (particularly from
Nicaragua), and the cost of being an “illegal” immigrant had also increased
(see Chapter 4). Crossing this border undocumented could therefore be a
stressful experience. In his narrative Santos describes how he suffered from
hunger, having been robbed of the little money he had brought with him. After
only a week in Costa Rica, the police caught him and his friends, and Santos
describes that they suffered both mental and physical abuse during their
imprisonment.
Santos’ main narration about migration is one of suffering. The concept of
suffering includes many aspects – physical, psychological, social, economic,
political, and cultural. It embraces several negative emotional experiences,
such as anxiety, depression, guilt, humiliation, and distress, and also relates
to feelings of loss, social isolation and estrangement (Wilkinson 2005).
Suffering thus captures “the vulnerability of lived experience” (ibid, with
reference to Turner and Rojak 2001). As a negative emotional experience
suffering may – according to theories about emotions, embodiment, and
health – be seen as influencing health negatively.
The interviews with Maribel and Rosa also highlighted that the NicaraguaCosta Rica border could be difficult to cross without legal documents. Maribel,
a single mother working as a nurse in León, had on one occasion gone to Costa
Rica undocumented, because her passport had expired. Similar to what Santos
described, Maribel had paid smugglers to help her with the border crossing.
Maribel:
“I paid some smugglers [coyotes] who were there, who said they were
smugglers, and they took me across the border. We walked over the mountain,
well, they [Costa Rica] have made a wall, so behind that wall is the mountain
where you can pass. They [the smugglers] pay the Costa Rican border guards
so they let people pass.”
Maribel’s account of border crossing is thus not as dramatic as Santos’, though
she had to rely on the smuggler’s good will in order to cross the border. Her
narrative also highlights that the border police were involved in the smuggling
activities, since they let her pass after receiving a bribe. Luckily, Maribel had
not experienced more difficulties; however, according to Morales, Acuña and
Wing-Ching (2009), female migrants travelling in the borderland of
Nicaragua and Costa Rica are often subject to sexual abuse during the border
crossing (as “payment” to continue the journey).
Rosa had gone to Costa Rica three times, two of them with her husband, who
later died in Hurricane Mitch. On all three occasions, she had walked over the
205
mountains to reach the border. Once she had travelled together with others,
in a group of 17. Rosa described in the interview that she had always walked
at night to avoid being detected by the border patrol; and that she had crossed
the border at night and ended up at a highway, where she and the others she
was travelling with had to be on the lookout to avoid being seen by the cars
passing by.
Rosa:
“I always went over the mountains, we passed guard posts... […] We crossed
at night… And during the day we tried to find somewhere to stay or walked in
the mountains. And past the posts at night. We crossed [the border] running,
we came to a highway and when we saw a car we dropped down on the ground,
so the vehicles wouldn’t see us. It took us a day to cross…”
Rosa’s narrative, like those of Maribel and Santos, shows that, even though
the Nicaragua-Costa Rica border is not as well-guarded and difficult to pass
as the border to the US, the border crossing can be a very hard and stressful
experience.
According to Salvadorian immigration policy, Nicaraguans can enter the
country by use of a Nicaraguan identity card (cédula); however, in order to
stay there for a longer period, and to work there, one has to acquire a permit
(see Chapter 4). If one does not obey this law, “illegal” border crossings may
thus become necessary. Cesar, the Leónese taxi driver, had once gone to work
in El Salvador. He travelled there only by means of his cédula, but since he
stayed for six months and never extended his permit or applied for a work
permit, he knew he would be fined if he crossed the border on his way back to
Nicaragua. Therefore, he hired a smuggler to take him across the river
undetected.
Cesar:
“When I was on my way back, to Nicaragua, I couldn’t cross the border,
because I had to pay a fine [peague], as they call it. I said, the little [money]
I’m bringing, I won’t pay a fine, right. What I did was to pay one of these, they
call it smuggler [coyote]. He took only US$10 to take me over the river.”
“Legal” border crossing
When Cesar subsequently went to Costa Rica, he acquired a passport and a
tourist visa. He could therefore travel there by bus, and cross the border
“legally”, which naturally was more comfortable and less stressful than going
“illegally” via the mountains like Santos, Maribel and Rosa had done. Cesar
was thus in a somewhat more privileged position than the others, which
relieved him from a great deal of stress.
206
Juliano, who had been working in Miami for four years, had US residency,
which put him in an entirely different situation than the other migrants. His
journeys to the US did not entail the same risks as those who travelled
undocumented; like Santos, for example, who had experienced great suffering
during his attempts to enter the country. Both Juliano and his wife, Cindy,
commented in the interviews on the superior situation for Juliano thanks to
his residency, in comparison with undocumented migrants in the US who they
knew, or had heard of.
Hence, for most of the international migrants, legal immigration status was
central for the risks the border crossings entailed. Santos, who had tried to get
into the US undocumented, had been in a particularly vulnerable situation,
and had also endured great suffering. Carmen’s husband, Gilberto, had
managed to get across the border without much suffering, but was now
“trapped” in the US, since he could not risk going back to Nicaragua
unauthorized (thus an example of entrapment due to border politics and
undocumentedness, mentioned above). The interviewees who had travelled to
Costa Rica without passport and visa also describe certain difficulties and
stressful situations when crossing the border “illegally”. Cesar, who had a
slightly better socio-economic situation, could “afford” to arrange the
necessary papers (ID card, passport, visa), which relieved him from stress
while crossing the border. Juliano, who could pass the US border legally
thanks to his residency, was much better off than other, undocumented
migrants. Hence, the interview findings show that legal immigration status is
key in attaining a less risky, and less health-damaging, border crossing; and,
moreover, that if health problems arise during the border crossing,
possibilities to receive health care are severely limited.
Life in the new place
The interviewees told many stories about how the migrants’ health was
affected during the time away, which also had repercussions on the health and
well-being of the family members left behind. The negative consequences
demonstrate a great vulnerability for the migrants, involving a great deal of
stress and suffering. The undocumented international migrants were the most
vulnerable. The positive consequences involved, for example, a better social
situation, empowerment, and improved access to education and health care.
In the following, I will examine health consequences on four themes: new
environments, working and living conditions, access to health care and
medicine, and education and learning processes.
207
New environments
The migrants had one thing in common: the experience of moving to a new
place with new environments. Even though the act of moving to a new country
perhaps entails the most changes, closer moves can in fact also have stressing
effects, since all kinds of migration generally entail dislocation and disruption
– not only spatially but also socially, culturally, and environmentally – which
may be experienced as stressful. Leaving behind familiar settings and family
members, and adapting to a new place and culture, has been shown to be
stressful in many studies (see e.g. Gatrell & Elliott 2009). For example, the
processes of “estrangement” (Ahmed 2000) and “cultural bereavement”
(Helman 2007; with reference to Eisenbruch 1988) may cause stress in the
individual migrant. The reception at the destination may also be a stressor for
migrants (sometimes characterized by “othering”, xenophobia, racism and
discrimination). In this section I will examine some of the stressors the
interviewees talked about in the interviews – changes in culture, social life,
food habits, and climate – which all had consequences, either positive or
negative, for the migrants in the study.
Homesickness
Cecil Helman (2007) argues that major disruptions in the individual’s life
space take place when a person moves from one place to another. The severity
of these disruptions naturally varies depending on the context of migration
(refugees perhaps experience the most severe disruption). Helman (2007:
326) further states that “[t]he experience of migration as a profound
‘psychosocial transition’, is analogous in some ways with bereavement or
disablement”. “Cultural bereavement”, as Helman calls it (a term coined by
Eisenbruch 1988), captures the experiences of people who have lost their
familiar land and culture (see also e.g. Bhugra & Becker 2005). The concept of
cultural bereavement thus captures the feelings of loss that migrants may
experience when moving from one place to another. Several interviewees
referred to this experience: the feeling of a great loss of the old “homeland” (in
terms of either one’s birthplace or home community). For some, like
Fernando, this feeling was manifested by homesickness.
Fernando, who lived in Cuatro Santos with his two children while his wife
worked in Spain, had travelled to the US to look for work. Thanks to his
political position he had received a visa, which he had overstayed. For six
months he worked in construction; hard work that he was not used to,
Fernando said. Upon my question of whether there was anything else he
wanted to share with me, he replied:
208
Fernando:
“Never again…emigration is difficult for you. I’ve been [abroad] for a little
time, it’s difficult. Being away from your home, from your family…everything,
from your country… My village…I missed this place, the village… It’s difficult
to be there, difficult, difficult…”
Fernando thus experienced great homesickness; he missed his family, his
home, the village, and also his country. He stresses that it was difficult for him
to be away, and that he never wants to migrate again. Fernando expresses a
great deal of feelings in this narrative, of both a negative and a more positive
character, primarily sadness and longing, which according to Parrott’s (2001)
classification of emotions is an expression of the positive emotion love. Hence,
feeling homesick entails a mix of negative and positive emotional experiences,
and depending on how the changes in milieu are experienced, I would assume
they produce various levels of stress for the individual.
Changes with bodily effects
According to Sarah Ahmed (2000), migration is characterized by
“estrangement”; that is “a process of becoming estranged from that which was
inhabited as home” (p. 92). Migration affects our place-based feelings, our
feelings of home and of belonging, and is an embodied experience, intimately
felt in the body, since “the journeys of migration involve a splitting of home as
a place of origin and home as the sensory world of everyday experience” (ibid.
p. 90). Therefore, there is a certain discomfort in inhabiting a migrant body,
for it is “a body that feels out of place”, Ahmed writes (p. 91).
Some of the embodied experiences of migration that Ahmed may refer to
concern the changes in climate and food habits that migration often brings
about. Regarding the change in climate, for example, Cesar mentioned that
his skin had been affected when he travelled between Nicaragua and Costa
Rica.
Cesar:
“When I returned here [to Nicaragua], the change came. I went to Costa Rica
from a hot climate, the climate here, and it was different there… The cold
climate affected me very much….because…well, my skin was affected [se me
enroncho la piel], because it was cold. I got a fever. […] When I returned to
Nicaragua I was affected a lot because…from the cold to the hot… My skin
really bothered me [la piel se me estaba fregando la cara]…”
Similarly, Juliano said that he got colds more often in the US because of the
change in climate, which was different in the US than in Nicaragua, and also
because of the exposure to air conditioning at workplaces. He also said he had
209
lost weight due to the different food culture, and that he missed the taste –
and the social aspect– of a home-cooked meal with his family.
Juliano:
“Well, the change…you feel it. There [in the US], everything is different. You
mainly get colds [gripe], because Miami is a sunny city… And, the change to
be working in buildings with air conditioning. Or, that it’s sunny in the
morning and rains in the afternoon. […] Those of us who aren’t used to it…feel
it a lot, we get colds, very strong colds. And also the food…when you get there
you lose a lot of weight, because of the change. You have to get used to it, to
eat alone, conserved food [enlatado]… […] Sometimes you have to choose to
eat fast food, like hamburgers, pizza… […] This damages you, you slim down,
because of the hard work, the bad food… It’s not the same as when you eat
food here [in Nicaragua], tasty, freshly made… with the family…”
Hence, the move to a new country involves a process of estrangement of the
body, for example due to changes in climate and food culture. For Juliano and
Cesar these changes – this estrangement – were intimately felt in the body,
thereby producing effects on health.
The stress of “othering”
Migrants have often been viewed as a “threat”; a view connected to the “fear
of pollution” (Douglas 1966). As a result, migrants are often “othered” because
of their “different” bodies (see e.g. Ahmed 2000; Sandoval-García 2004).
Processes of “othering” (including the fear of “others”/“strangers”, i.e.
xenophobia) and of racism (including the discrimination of certain groups)
may produce stress and other negative health consequences for migrants.
Gatrell and Elliott (2009) state that it is not uncommon for migrants to
experience a poor reception due to xenophobia, and that they may suffer from
feelings of alienation and sometimes depression as a result. Williams et al.
(2003) and Paradies (2006), through their reviews of research on the relations
between health and discrimination and self-reported racism, show that there
are clear associations between perceived discrimination (experiences of
“racial” bias) and poor physical and mental health status, as well as between
self-reported racism and ill-health, especially poor mental health.
Furthermore, longitudinal studies have shown that self-reported racism
precedes ill-health, and not the opposite161. The findings are generally
consistent with the greater body of literature on stress and health. That is,
systematic exposure to stressful experiences of discrimination and racism may
have long-term consequences on health – directly, through influencing the
161 However, as the authors state, there are methodological limitations in these studies (e.g. definition and
measurement of discrimination and racism), and the knowledge is still lacking regarding the conditions and
mechanisms involved in the process. For example, there are uncertainties regarding the relation between racism
and stress (i.e. whether racism is distinct from other types of stressors). Moreover, most studies have been
conducted in the American setting.
210
body’s physiological stress responses, as well as health behaviours (resorting
to high-risk health behaviours such as substance abuse and self-harm) and
other negative coping responses (e.g. delays in seeking health care), and
indirectly, through influencing the individual’s opportunities in life (e.g.
education and employment), and consequently social position and social
status, which are important social determinants of health (Paradies 2006).
Many interviewees, especially the international migrants, had experienced
“othering” – xenophobia and racism – in terms of discrimination and
maltreatment, as well as a fear of violence. For example, when Maribel was
living in Costa Rica she was subjected to many negative personal comments
because she was Nicaraguan, and also about Nicaraguans in general. One of
her workmates, for example, had made rude comments to her. She was
emotionally affected by all the negative comments she heard, and experienced
it as very stressful.
Maribel:
“Living in Costa Rica was very stressful… The Costa Ricans [los ticos] hissed
at the Nicaraguans [los nicas], saying things that they aren’t… […] I don’t want
to go back there… The ticos are very harmful towards nicas, they try to
humiliate you, it’s very… They say that the nicas come to take their jobs, their
medicines, [their social] services… […] At one of my jobs there was a Costa
Rican who seemed to dislike Nicaraguans. I asked him a favour, and he told
me ‘Go home to your country, stop messing around here [dejen de joder], go
away, you’re only here to cause harm [solo vienen a joder]’.”
In this quote Maribel gives a personal picture of what it feels like to be
“othered”, and discriminated against because of one’s national identity. She is
far from the only Nicaraguan (nica) to experience this, however, as the general
discourse in Costa Rica about nicas is that they are a “communist threat”, and
they are often believed to be connected to crimes, insecurity and disease
(Sandoval-García 2004). According to Carlos Sandoval-García (2004), the
“othering” of Nicaraguan migrants is very strong in the case of Costa Rica,
where “the Nicaraguan ‘other’ is frequently associated with a turbulent
political past, dark skin, poverty, and nondemocratic forms of government”
(ibid. p. xiv). One reason for this, according to Sandoval-García, is that the
“poor and dark-skinned Nicaraguan” (ibid. p. xxii) has played a crucial role in
the construction of the Costa Rican national identity. You might recall Gloria’s
statement (p. 141) about her sons – that they had not emigrated to Costa Rica
and El Salvador “for vice” (para vicio), but to improve their economic
situation – which indicates that there indeed exists a negative discourse about
Nicaraguan migrants, even among Nicaraguans themselves.
Going back to Maribel, she opposed the bad sentiments about Nicaraguans,
through saying that nicas are not lazy, that they work very hard (nicas no es
211
haragán, trabaja muy duro), and that Costa Ricans (los ticos) are wrong to
think they themselves are superior. Other interviewees also mentioned these
types of negative stereotypes of Nicaraguan migrants, and most opposed the
bad image Nicaraguans were given. Dissociating oneself from this negative,
xenophobic discourse through defending the Nicaraguan migrants, which for
example Maribel and Gloria do, can be regarded as a type of coping strategy,
i.e. as a way to tackle the negative feelings the degrading opinions might cause.
At the same time, Maribel also excused the Costa Ricans for some of their bad
behaviour towards Nicaraguan immigrants, as she believed there were
reasons behind their low opinion of nicas. One could say that she had
internalized some of the xenophobic sentiments regarding Nicaraguans.
Maribel:
“What happens with the nicas is that…there are a lot of people who come [to
Costa Rica] to do harm, I won’t say the opposite. That ticos talk bad about
nicas is because there are nicas who come to do a lot of harm. ”
In relation to this, Maribel gave examples of fights and homicides among
Nicaraguan men and women because of jealousy, and of a bank robbery in
which a Nicaraguan man had killed several people. Another, very offensive,
example I also heard about during my fieldwork involved a Nicaraguan man
who was attacked by dogs in connection to a robbery, and no one came to his
rescue. Many were upset that this could take place at all; Maribel too, but she
also excused it slightly due to the fact that the man was actually conducting a
robbery.
Maribel:
“[O]ne who got into robbery, and they set the dogs on him – it was global news,
how dogs were eating Nicaraguans in Costa Rica… […] I was there when it
happened. People rioted, since it was something that was filmed when it
happened, and broadcasted. ‘How is it possible to set a dog on a human being’,
many nicas and ticos said. They said so, well the dogs were set on him because
he was stealing, but he was a human being… ”
Hence, the interviews, for example Maribel’s, showed how processes of
“othering” can produce highly tangible effects for the migrants who experience
them. The stress of “othering” included both verbal and physical abuse as well
as discrimination. The interviews also showed how the stigma following the
negative discourse about Nicaraguan migrants was coped with; how it was
internalized and excused, and resisted and reworked.
Positive changes – improvements in social milieu
For some interviewees, the changes migration entailed in the social
environment was positive for their health. This includes Marta, for example,
who was relieved from physical and mental abuse when her husband migrated
212
to Costa Rica, and Ana, who escaped the abuse she had been subjected to in
her family when she left for León. Ana’s new social situation in León was a
great improvement, she said, and she felt that both families she had worked
for during her time in León were like her new family.
Ana:
“La señora [the first employer] was very nice to me…she gave me a lot of help.
I was sick, like six years ago I was sick, when I came from there [the home
community], I had a fever, a cough… I had a blister on my foot, I had to have
my foot operated on, I couldn’t work for several days. But, la señora helped
me a lot. They [the family] took me to the hospital, they gave me medicines
and all, right. I had to have treatment for like two months, and she took good
care of me, with the food, and attention. For this, I’ve felt good, where I’ve
gone [to the employers] they have taken care of me, they’ve never looked at
me like…a stranger, right. Nor have they been suspicious of me. […] And X
[her present employer] has helped me a lot too…she gives me advice…I feel
good with her… I feel like I’m alright, not that I’m far away [from home]… I
don’t feel that bad to be away from my family… I feel like I have another new
family now; that helps me and all.”
For Ana, the move to a new place was thus an improvement, socially. Through
moving she was relieved from the stress of her family situation, and felt less
like a stranger in the new place than within her own family. Hence, migration
does not only produce stress for the migrant because of the changes in sociocultural milieu; it can also lead to improvements.
In this section I have discussed some of the changes and effects the
interviewees talked about in relation to migration to a new place: processes of
estrangement and bereavement – including changes in social life,
homesickness, changes and effects of a new climate and new food habits, as
well as the stress of “othering”. Though the interviews mostly showed the
negative effects of migration, some interviewees experienced the positive
effects from the changes. The findings thus highlight the diversity of the
consequences of migration.
Working and living conditions
A central theme in the interviews was the situation of work and housing for
the international migrant workers. Many of the international migrants faced
precarious working and living conditions, and many talked about the
difficulties of migrant work, and of bad housing situations. Nevertheless, the
improved economic situation many experienced thanks to the migrant work
also had positive effects on their living conditions back home, which for many
made the tough times as a migrant worth it.
213
Health can be profoundly affected by work relations; in terms of both what
type of work is performed, and the social relations and social structures
surrounding the work process. Through work, the body is intimately
connected to larger socio-economic relations, often characterized by unequal
power relations (Wolkowitz 2006). Today’s global, capitalist labour system is
not only polarized, i.e. hierarchically organized and geographically
differentiated; it is also racialized and gendered, and exploits workers based
on their social position (Bonacich et al. 2008; Lugones 2007). Migrant
workers are also part of these processes; and, those who have a lower socioeconomic status – e.g. those in the middle layers or the lower positions,
according to Anja Weiss’ (2005) typology, where the migrant workers in this
thesis would be placed – have a much harder time crossing national borders,
especially to enter richer countries where there is a demand for their labour.
“Illegal” border crossings may take place as a consequence, entailing much
higher risks for the migrant. Moreover, the relations between workers and
employers (as well as their identities) have changed, and work today is
characterized by more unequal power relations, which also may have diverse
effects on health (Wolkowitz 2006). For example, the transnationalization of
reproductive labour (e.g. Ehrenreich and Hochschild 2002) – through which
migrant women from poorer countries leave their families and children to take
care of the reproductive work (child-rearing and household work) in richer
families in the North – produces racialized hierarchies between employers
and employees, which influences the migrant workers’ health.
The labour system in place today is also characterized by a high degree of
precariousness (Standing 2014). According to Standing, the precariat suffers
from a precarious (or, vulnerable) existence due to labour insecurity (e.g.
temporary and part-time jobs; on the rise because of the neo-liberal
economy’s need for flexible labour), insecure social income (particularly a lack
of community support and other benefits), and lack of a work-based identity
(e.g. careerless jobs, with sudden changes or resignation, often under the
employee’s skill level). Standing argues that those in the precariat “are
becoming denizens rather than citizens” (ibid. p. vii), lacking e.g. social,
economic and political rights. There is research that points to the negative
health effects of precariousness. For example, Tompa et al. (2007) state that
the stress caused by, for instance, job insecurity and low job satisfaction is the
most important pathway from precarious employment to health. In the
context of this study – Nicaragua – it might be argued that these aspects are
not as relevant, due to the low level of formalization of the labour market
historically. Nevertheless, Nicaraguan workers – particularly those in the
informal sector or free-trade zones – are definitely immersed in the context of
precarious labour relations. Moreover, Nicaraguan migrant workers, like
other migrant workers, are in a particularly vulnerable and precarious
214
situation. Standing (2014) claims that many “denizens” are immigrants, which
points to this group’s marginal position. In a UK context, Linda McDowell and
colleagues (2009: 4) state that “economic migrants, apart from those
recruited directly into skilled occupations in, for example, banking or health
care, are often forced to accept the most precarious labour contracts, in jobs
incommensurate with their skill levels”. The most vulnerable workers,
according to Wolkowitz (2006), can often be found in “dirty” and low-paid
jobs, such as cleaning and agriculture; sectors which often have an
overrepresentation of migrant workers. Thus, while migrant workers are not
the only ones working in precarious jobs, they are particularly vulnerable
because they are newcomers who are less familiar with the labour market, and
often also have fewer rights (McDowell et al. 2009). Especially undocumented
migrant workers are in a precarious situation. Goldring and Landolt (2011)
have found that a precarious legal status has long-term, negative effects on job
precariousness, even when the migrant shifts to a more secure legal status (i.e.
regularize). However, as these authors state, migrant worker insecurity and
vulnerability does not stem only from irregularity, but also from the migrant’s
social position (ethnicity/“race”, gender and class). McDowell et al. (2009:
20) also point this out, saying that all migrant workers “are not equally
vulnerable to exploitation, nor are they all permanently trapped in precarious
forms of work”. In their study they found, for example, a hierarchy within the
group of migrant workers depending on country or region of origin, legal
status, ethnicity and skin colour. Non-European migrants without a legal right
to stay in the UK, or without a work permit, were found to be particularly
vulnerable and in the most precarious work situations. Moreover, white
migrant workers were premiered, and were therefore not as subject to
vulnerable and precarious situations (there are, however, certainly degrees of
“whiteness” as well as “blackness”, which are important to acknowledge162).
Brabant and Raynault (2012) furthermore show that migrants in Canada with
a precarious status (defined as immigrants with no legal status or precarious
immigration status; that is, those with neither permanent status nor a
guarantee to stay temporarily) are disadvantaged in several areas that may
significantly impact on their health. For example, poverty was often reported,
as were difficult – and sometimes unacceptable – living environments and
working conditions. Mental health was affected by the difficult psychosocial
environment, and physical health sometimes suffered due to problems
accessing care. In relation to Nicaraguans living in Costa Rica, Catherine
Marquette (2006) write that Nicaraguan migrants are poorer than the Costa
Ricans, and their standards of living are below the national average. Fourty
percent of Nicaraguans in Costa Rica in fact live in inadequate living
162 The concepts of “pigmentocracy” and “colourism” highlight these issues; see e.g. Jackson (2015), and Hall
(1992).
215
conditions (20% of Nicaraguans in the capital San José live in slums).
Furthermore, Nicaraguans are concentrated in low status and low paying
occupations, partially explained by the irregular status of many Nicaraguan
migrants, which makes them accept inadequate working conditions.
Additionally, Nicaraguans often lack health insurance, but they usually have
access to public health care, though this often is of poor quality.
Undocumentedness, risks and discrimination
Irregular/undocumented migrant workers are thus in a particularly
vulnerable and precarious situation on the labour market, also in Costa Rica.
This was highlighted in several interviews, for example by Maribel and Cesar.
Maribel had spent most of her time in Costa Rica undocumented. On her last
trip she had obtained a false Costa Rican identity card (cédula), because at the
time this was required by law in order to work. Thanks to her false cédula
Maribel could get not only jobs, but jobs with a higher salary. In the following
quote, she explains the importance of having a cédula:
Maribel:
“One is much more peaceful [tranquila] with the identity card [la cédula]
because when the police [migración] come by the workplace they see that
everything is legal. But before… I worked for three years before without a
cédula, without security. Without those documents one loses the security, so
of course the boss pays you what he wants without it.”
Maribel thus highlights that the cédula (although it was false) made her feel
more peaceful, because she did not have to worry about getting caught by the
police if they visited her workplace. She also relates this to her previous
experiences of being undocumented; that she then had felt less secure, less
peaceful, and had fewer rights in dealings with employers. This points to the
precarious and vulnerable situation in cases of undocumentedness.
Maribel continued, saying she had sometimes had to work outside San José
(the capital) because the jobs there were better paid (so that she would be able
to send more money to her children in Nicaragua). However, these places were
often much more dangerous, Maribel said:
Maribel:
“There are places that are dangerous, it never stops being dangerous…to
walk…very dangerous.” <<C: In what way is it dangerous?>> “A lot of
assaults, a lot of assaults, a lot of police [migración] and if you pass through a
place and lose your bag no one does anything. […] I’ve been assaulted several
times.”
216
Because of Maribel’s need to make more money, she thus had to work in more
dangerous settings where she risked being robbed or caught by the police. She
also mentioned that she had experienced a difficult situation with housing,
and that she had occasionally been treated very badly by landladies (she had
been both robbed and psychologically abused). Maribel had thus been in a
vulnerable position due to her undocumentedness during her years in Costa
Rica, including risks and discrimination. The vulnerability of being an
undocumented migrant was somewhat slighter after she had acquired the
false cédula, but she was nevertheless “lawless” in the face of the police, and
had also endured a great many assaults. Maribel had also been in a vulnerable
position in her housing situation. Her narrative thus shows the stress one can
live under as an undocumented migrant.
Cesar had also experienced the difficulties of undocumentedness. He had
lived in El Salvador for six months, having entered the country legally but
overstaying the one-week visa he had acquired on entry. In El Salvador Cesar
had worked with road construction, but he had left the country because he did
not like the work situation, particularly the low salary and unsafe working
conditions, which he describes in the following quote:
Cesar:
“The work I did in El Salvador was in road construction. So, the boss, as we
can call him, he hired people who didn’t have a passport or ID card [cédula],
so that he could pay them less. So, the police [migración] never came there to
say to him, to see if people were safe; if they fell from a vehicle it was their own
problem, right. I worked in welding, without protection from a mask or
anything, only the mask you put on to protect your eyes.”
This narrative highlights the precarious situation undocumented migrant
labourers may encounter (low pay, unsafe work conditions). On his way back
to Nicaragua, Cesar passed Honduras. He only stayed for a week there,
however, because of the criminal gangs he said often robbed migrant workers.
Migrants’ precariousness and vulnerability may thus also relate to the risks of
violence and robbery, which Maribel’s story also highlighted.
When Cesar went to Costa Rica shortly thereafter he worked for a company;
first with welding – a work he enjoyed because he made good money, although
the work itself was very strenuous.
Cesar:
“In Costa Rica, you get good money working in construction, but…it was hard
work. I started working at six in the morning and didn’t quit until nine or ten
at night. It was very exhausting. It was like that from Monday to Saturday, and
on Sundays I started at nine in the morning and quit at five in the afternoon.
It was very exhausting. But some Sundays I was off work, if they were out of
building material. Then I could relax.”
217
As Cesar describes, the work he did was very hard, entailing long working
hours and few days of rest. Since he was in Costa Rica undocumented the work
situation could also be dangerous, as he explains in the quote below. Cesar did
not have sufficient protection for the kind of work he was doing, and his
employer did not provide insurance for him or the other migrant workers,
which could prove difficult if health problems arose.
Cesar:
“The thing is, in Costa Rica there’s no insurance, all the insurance is for the
Costa Ricans [los ticos] and those who work in an office. […] But… Do you
know what something called metobo is? It’s a disc of iron, it’s like a pistol, a
machine [a metal saw]. And, it sparks…when it cuts, it throws off sparks. And
if you don’t have eye protection, you get burnt in the eyes… And, you might
lose an arm… And you don’t have any insurance…” <<C: Didn’t you have any
protection?>> “There, they don’t give you anything. There, if I welded things
of metal… If I welded in bronze, then yes, they gave protection, but… So, it was
really dangerous…”
Cesar’s story thus shows the precarious and vulnerable situation
undocumented migrant workers may face, that also can produce serious
effects on health and access to health care. Luckily, Cesar was appreciated by
his employer, and was soon promoted to team leader with an increased salary
as a result. When the company went through economic difficulty and had to
lay off workers, Cesar even had the opportunity to start working in the office
instead of being laid off. He was very content with this at first since he had the
chance to practise his profession (computing). Nevertheless, he made much
less money in his new position, and also experienced a great deal of
resentment from his Costa Rican co-workers.
Cesar:
“I worked in the office, but I didn’t like it, because I made very little money,
only like for sustenance in Costa Rica, I couldn’t send anything to Nicaragua.
[…] [And] because I was sitting in front of a computer all day … I told them I
had studied computer science here in Nicaragua, but it wasn’t for me, sitting
all day, doing office work… […] When I came to work, they looked at me like I
was weird [se mira cómo extraño], because all of them were Costa Ricans
[ticos]; only some were Nicaraguans [nicas]. And…even more when I became
a team leader, more irritation [más molesto], because they said ‘Who do you
think you are…a nica who just started working here and is already a boss, and
all the rest of us who’ve worked here for years and who are ticos and have
never worked as bosses’... […] So, I said to myself that this didn’t serve me
well. And, I decided to go back to welding to make more money. Then, when
the company went bankrupt I tried to find a new job, but no one gave me one
because I didn’t have a Costa Rican ID card [cédula tica].”
Cesar’s narrative highlights the “othering” of Nicaraguans in Costa Rica, and
the negative emotional experiences this may give rise to. It also shows that
undocumentedness may lead to difficulties finding work (Cesar’s experiences
took place after a stricter immigration policy had been enacted in Costa Rica,
218
see Chapter 4). The narrative also shows that Cesar had been able to work for
a while in a more qualified position relevant to his education when he was in
Costa Rica. He thus had the opportunity to make use of and possibly increase
his human capital; however, due to the low salary (and because he did not like
it) Cesar did not pursue this career, because of his need to make more money
to support his family. For Cesar, migration was thus more a strategy for
making a living for the whole household than an individual pursuit for his own
sake (i.e. a practice of mobile livelihoods). The structural conditions made it
necessary for Cesar to choose the less qualified job since it provided him with
more money, and therefore his migration did not produce any major effects
on his human capital (which is important for health).
In sum, Maribel and Cesar’s stories show how migrant workers – especially if
they are undocumented – are exposed to structural discrimination in the
labour market as well as a rightless situation that can produce negative effects
on health.
Working in the “maquila”
Joanna had worked for seven years at an assembly plant (maquila) in
Guatemala. She mentioned in the interview that the work in the factory was
quite hard. The working days were long, which caused fatigue, and on top of
this she was sometimes treated badly by the directors. She nevertheless
endured it, thanks to the fun atmosphere with her workmates and, most
importantly, the money she was making.
Joanna:
“What I did there [in Guatemala] was work in an assembly factory [maquila],
where they make clothes, where they put together pieces, I worked with all
those things.” <<C: How was the work in the maquila?>> “Heavy… There,
we worked until two at night, very tiresome, tiresome [cansado]… And
sometimes the bosses, the owners, they treat you…they get angry, they yell at
you… Just like it was tiresome, it also was fun, with my workmates, you passed
the time, but yes, you made money too.”
Joanna’s story shows a precarious work situation for migrants, even during
“legal” circumstances.
Being “invisible”
Rosa had worked in Costa Rica for several years, but in contrast to Maribel
and Cesar she had mainly good experiences from that time, even though she
had been there undocumented. Rosa had encountered nice, helpful people,
and her work situation had always been good. She believed that part of the
reason for her good experiences was related to her “whiteness”; i.e. that her
219
pale skin colour made her look more Costa Rican than Nicaraguan, which
meant that she did not have to endure as much xenophobia as other
Nicaraguans. Additionally, since she had usually stayed overnight at her
workplace – when she worked as a live-in maid, and again at a restaurant –
she had been more “invisible” than others, thus avoiding detection by the
migration police.
Rosa:
“The last time, I was a kitchen assistant. When I came to her [the employer],
she liked me. I slept with her, in the same bedroom, which no other employee
had done before. When someone came and asked, she always answered that I
was her granddaughter, or her niece, she never said I worked for her. Well, a
lot of people say they’re treated bad there [in Costa Rica], that they don’t like
us because we’re Nicaraguans. But… When I left for Nicaragua, she [the
employer] gave me presents, a lot of clothes, and she cried when she said
goodbye to me. […] Imagine, at least, the police never found me. […] Since I’m
white [blanca], and the majority of ticos are white, so I tell myself that I get
mixed up with them [me confunden con ellos]… And, my work… I worked in
homes, and when I was there alone I didn’t go out, I stayed in.”
Hence, Rosa had been in a less vulnerable situation, and experienced less
suffering, than many other undocumented immigrants in Costa Rica, thanks
to her work environment (indoor work, nice employers), and “whiteness”.
This shows that type of work and skin colour may be important for the
experiences of migration; i.e. for the degree of precariousness, vulnerability
and suffering, and the resulting consequences on health. Rosa’s story also
highlights the transnationalization of reproductive work (e.g. Ehrenreich and
Hochschild 2002), whereby women from poorer countries migrate to work as
maids and take care of the reproductive work in richer families; here in the
context of south-south migration. Racialized hierarchies between employers
and employees are often in play in this process; however, for Rosa this was not
the case thanks to her “whiteness”. Nevertheless, her position as an
undocumented migrant did cause other types of stress, e.g. in connection to
health care visits.
Being a “legal” immigrant
The kind of stress and vulnerability that Rosa, Maribel and Cesar went
through due to their undocumentedness was not experienced to the same
extent by the “legal” immigrants. Juliano, who was a US resident, had a much
better work situation than did undocumented migrants. For all the years he
had worked in Miami he had worked in painting with his father, and later also
with his brother. Thanks to his legal status he had been able to advance to
better jobs as well. In the interview he said he knew many undocumented
immigrants in Miami, also Nicaraguans, who suffered from exploitation and
maltreatment at workplaces (i.e. precariousness). Due to their “illegal” status,
220
Juliano said that they faced much higher risks than those who are “legal” and
can protect their rights.
Juliano:
“I know a lot of people [undocumented Latinos] there…it’s difficult for them.
Especially for the risks… If a person who is undocumented [no tiene papeles]
gets hurt at work, he/she can’t reclaim anything, can’t ask, can’t demand
[anything] of the company, they can’t. […] For these people it’s more difficult,
there’s more exploitation for them, they [the employers] pay them what they
want, and they don’t report anything [no van denuncian], out of fear… And
they really mistreat them…because they don’t have papers, documents… I
know a lot of people…”
Being an undocumented migrant was thus, according to Juliano, more
difficult than being a “legal” resident like himself, with all the rights and other
advantages it entails. Juliano’s narrative shows that undocumented migrants
are in a more precarious situation, entailing more risks at work, less salary,
maltreatment, and with no possibilities to make claims on the employer out
of fear of being reported to the police; and that “legal” immigration status led
to less precariousness and vulnerability, and reduced levels of stress.
Learning new skills
Several interviewees talked about having learnt new skills in relation to their
migration. I believe it is important to include learning processes in relation to
migration when discussing the relations between migration and health, since
educational attainment and social status in general are well-known
contributors to good health.
Juliano highlighted in the interview that he had had the opportunity to take
different courses in the US to enhance his skills as a painter. He had learnt the
profession from his father in Nicaragua, but it was only after migrating that
he experienced that he had received a “proper” schooling.
Juliano:
“There [in the US] I got an education. Here [in Nicaragua], no. I learnt it from
my father…he worked as a painter here. […] So, as a child, I learnt it [yo me
venia fijando]. Well, there [in the US] it’s different…there, to make an
“escape” [un escape], they send you to take a course for whatever risk there
might be, there they teach you how to use machines. It’s not like here… There,
since they set things up quickly, everything’s machine-run… There, they teach
you, it’s mainly short courses, they give you short classes [capacitación].”
In the quote, Juliano stresses the great difference between Nicaragua and the
US in terms of the education required to work as a painter, and said he had
received education and learnt new things for carrying out the profession in the
221
US. This shows that through migrating, new skills can be acquired, which can
enhance human capital and have indirect effects on health.
Other interviewees talked about the skills they had acquired after migrating
from rural to urban areas within Nicaragua. Ana, for example, had learnt a
whole new profession upon moving from the mountains to León. At first,
however, she had felt “bad” because she did not have the capabilities required
in the city.
Ana:
“When I came to León…I was here in León for a while without working, right.
I felt bad, because I didn’t have a job…I couldn’t do the kind of work that was
available here in the city. So…but…thank God, I met a lady who helped me a
lot…she taught me how to clean, to do laundry, to iron, to cook, all that.”
Ana thus felt incapable of performing the kinds of jobs available in the urban
context, and felt “bad” because of this. One may interpret this as Ana feeling
ashamed at her lack of skills. Shame is a common emotion when it comes to
the experience of differences in socio-economic status (social class) (see e.g.
Reay 2005; Felski 2000). As Ana mentions, she luckily found someone who
could train her, which enhanced her self-esteem. She also mentioned in the
interview that she dreamed of taking reading and writing classes, which she
might be able to do now that she lived in Léon. This thus points to the
importance of internal migration for learning new skills.
In sum, the narratives on migrants’ working and living conditions expressed
how working conditions are often characterized by precariousness and
vulnerability, which sometimes have – or may have – serious effects on
migrant health. Immigration status and skin colour were emphasized as key
in how the migrant’s situation plays out. Some migrants had enhanced their
human capital through migration, which may have indirect effects on health.
Access to health care and medicine
Many of the interviewees mentioned that migration events had led to changes
in their access to health care and medicine. For some, primarily the internal
migrants, the migrant’s access to health care had improved after moving from
a rural to an urban area. For others, predominantly the undocumented
international migrants, the access to health care had become more limited.
The localization of health care services, and people’s distance to them, are
important for the access to and use of health services (Gatrell & Elliott 2009).
The question of distance as a constraint on people’s utilization patterns has
received a great deal of attention in research; however, due to close
connections to the issue of area deprivation the question is rather complex.
222
There is, however, evidence of a clear distance decay relationship between
physical distance from health services and health-seeking behaviour, meaning
that people living farther from health services seek health care more seldom
(Gatrell & Elliott 2009). The reasons behind the distance decay relationship
include, for example, time-space constraints, and costs in terms of time and
travel, that deter people from seeking care. However, it is not only physical
distance that is important for people’s use of health care. Social and cultural
factors, for example, are also important for people’s utilization patterns; for
example, affordability (that is, being able to afford the costs, not only of travel
but also of health care), cultural barriers (e.g. appropriateness, language), and
social marginalization (e.g. of the homeless) (ibid; see also Curtis 2004). A
distance decay effect also seems to exist in developing countries (e.g. Muller
et al. 1998, referred to by Gatrell & Elliott 2009; and Feikin et al. 2009,
referred to by Anthamatten & Hazen 2011). Yet, a more important question in
these regions is perhaps whether there is an adequate overall level of health
care delivery at all, particularly concerning primary care, and whether this
care is not only geographically concentrated to urban areas (Gatrell & Elliott
2009). In relation to areas in the North, Anthamatten and Hazen (2011: 158)
write that “the impact of distance is often especially significant in rural
communities”. This certainly applies to rural areas in the South as well. In
combination with generally poorer health in rural communities163, the poorer
access to health care can sometimes lead to an even more vulnerable
population. In response to the health needs of rural populations, some
countries (e.g. Nicaragua and Costa Rica) have set up a system of rural clinic
outposts (called health posts in Nicaragua; see Chapter 4). In Nicaragua, there
are substantial inequities in the access to and use of health care services
(Angel-Urdinola, Cortez & Tanabe 2008). Most of the health care services are
located on the Pacific coast, with the result that access to care, particularly
more specialized care, can be very limited in sparsely populated areas (e.g. the
Caribbean region). In Nicaragua, there also seems to be a distance decay
effect; according to Angel-Urdinola, Cortez and Tanabe (2008), the distance
to health services in Nicaragua influences the access to and utilization of
health care (for each kilometre the probability to use health services decreases
by 0.2%). Additionally, those in the Pacific and central regions are more likely
to seek and receive treatment than those in the Caribbean region (probably
due to the longer distances to health care facilities, but also to lacking
services).
In relation to the general trends in health care organization and localization,
one may argue that rural-urban migrants, in general, improve their access to
163 This paradox – that those with the greatest health needs often have the poorest access to health care services
– is sometimes referred to as the “inverse care law” (Hart 1971, referred to by Anthamatten & Hazen 2011).
223
health care when moving into urban areas. However, this of course largely
depends on the distribution of health services in rural versus urban areas, and
where people live in relation to services. The access to more specialized health
care is nevertheless generally better in urban areas throughout the world,
particularly in developing countries, and this is also the case in Nicaragua.
Besides physical distance there are also other barriers that negatively
influence people’s access to health care, such as economic and cultural
constraints, which certainly also apply to rural-urban migrants.
In the literature, the issue of migrants’ access to health care is discussed
primarily in relation to international migrants. Hargreaves and Friedland
(2013) state that existing studies show that immigrants in Europe – even
though they may be entitled to health care – often face certain barriers in the
access to health care, which influence service use and may explain patterns of
ill-health. The barriers the authors mention include both personal and
structural factors: for example, age, sex, socio-economic status, ethnicity,
language ability, proximity to health services, and health-seeking behaviour,
as well as health policy and health care delivery system. Furthermore,
Hargreaves and Friedland state that newly arrived immigrants (e.g. asylumseekers and undocumented migrants) face particular constraints, including a
lack of entitlement to free (publicly funded) health care (whether actual or
perceived), lack of access to appropriate health care according to one’s needs,
and a lack of knowledge about how the care system works. Discrimination by
health care staff is yet another problem, and is perhaps experienced to a higher
degree by new immigrants since there might be confusion as to their rights.
Indeed, as Jasmine Gideon (2013: 167) writes, “[m]igrant status is critical in
determining individuals’ and their dependants’ access to healthcare services”.
Furthermore, in relation to the Chilean case, Cabieses and Tunstall (2013)
argue that – even though there may be laws and regulations regarding
immigrants’ health rights – socio-economically vulnerable groups
(particularly economically marginalized immigrants and undocumented
immigrants) are still limited in their access to health care in Chile. Socioeconomic position seems to pose the most important constraints for these
groups, along with discrimination and a lack of understanding of the health
care system (see also Gatrell & Elliott 2009). Studies from Costa Rica also
show that Nicaraguan immigrants in this country have limited access to health
care because they often lack insurance, and particularly undocumented
migrants have trouble accessing health care (Morales & Castro 2006).
Rural-urban differences
Ana and Marta, who originated from rural areas, both said that the access to
health care was a great deal better in León than in their home communities.
224
Marta talked about how much easier it had become to go to the doctor and get
treatment for her children after moving to León. And Ana, who came from a
remote rural area, said it was very easy to get to the health care services when
someone became sick in León, but that it was nonetheless sometimes difficult
to afford the cost of transportation.
Ana:
“[H]ere, if you get sick acutely…you call the ambulance or a taxi and are
already on the way, right, to the hospital. And they’re close…not like there [in
her home community]… What’s lacking sometimes is money, to mobilize
oneself rapidly, right.”
Even though the health services were close by in Léon, the cost of getting to
them could thus be hard for some to bear. However, in Ana’s experience,
people in León often helped each other in times of need. In comparison, for
those residing in Ana’s home village, the closest health care centre lay in the
nearest village, two hours away by foot, and the nearest hospital lay a whole
day’s walk away. Ana attributed the deaths of several of her siblings to the long
distance to the hospital, but also to the fact that they were too poor to afford
medicine. In the quote below, she describes how she had also been seriously
ill during her childhood, but that she had luckily received treatment in time:
Ana:
“I was 8 or 10 when I was really sick, with whooping cough. So we went there,
to the health care centre… But… my little brothers died…since it [the hospital]
was too far, we couldn’t take them fast to the hospital. Another brother and I
got treatment that helped us. But the other two children died. They were four
and five years old. […] Also, we had the measles too… Many of my siblings,
there were 15 of us, and out of everybody only five are left…all the others died
because of diseases. Since the hospital was so far away, they didn’t take us to
the hospital. And, medicine was expensive, we didn’t have money to buy it…so,
the children died.”
Ana thus emphasized that the distance to the hospital had severe effects on
the health of her family, but also that the family could not afford to buy
medicines when all the siblings were sick. It was thus both physical distance
and economic resources (affordability) that stood in the way of Ana’s family’s
access to health care. Often, when they could not buy occidental medicine, the
family instead used traditional medicine to cure illness, she added. I further
asked Ana what they did when someone was sick, and could not walk the long
distance to the health care services themselves. Help among neighbours was
then central, Ana replied:
Ana:
“You look for a group of people who can help you, to take you there in a
hammock, to carry the patient. Neighbours help each other to bring you to the
hospital, but there’s…nothing quick, no. And, if someone’s really sick and
there’s no hospital close by, there’s nothing to do… […] People help each other,
225
lend things to each other… ‘Here’s medicine’, ‘I’ll go and buy you that’… People
lend you…like a boat [lancha], if you need it… […] So, some give you ride on
the river, and that goes fast, but there are districts that are far from the river
and then you can’t get to the health care centre fast.”
Ana’s narrative highlights that the access to health care in rural areas in
Nicaragua can be very limited, and that help within social networks for
accessing health care in rural areas, for instance help with transportation, can
be crucial. The interviews also highlighted that the access to health care was
much better in urban than rural areas, and that their access had greatly
improved when they moved to the city (León). This confirms the proposition,
mentioned earlier, that the distance to health care services impacts the use of
health care, and highlights the importance of an adequate level of health care
in rural areas as well. Moreover, the study also shows that when the
distribution of services is uneven, social networks become crucial for attaining
care.
The advantages of being “legal” and insured
Regarding the international migrants in this study, immigration status, work
relations and insurance were important for the access to health care.
Joanna, who had worked in an assembly factory (maquila) in Guatemala for
seven years, felt – despite the maltreatment mentioned above – that the
maquila was a good place to work, since the factory paid for social insurance.
Thanks to this she had received prenatal care when she was expecting her
children, and was also taken care of when her second child had to be delivered
by caesarean section.
Joanna:
“Yes, they were very good to me, they were good to all the workers. They took
care of the pregnant women, they gave them insurance, and when you’d given
birth they gave you a break. […] And they attended to the children when they
were sick, I had insurance so they attended to them. […] I got sick, with the
baby, he was in breech position. They operated on me, it wasn’t a normal
birth.”
Besides the care surrounding her pregnancy, Joanna’s children had also been
helped during illness, thanks to her insurance from work. Joanna’s story thus
shows that social insurance provided by employers may be crucial for
receiving good care.
Juliano, who was a “legal” resident in the US, had not experienced any major
difficulties accessing health care, since he had insurance from work.
Nevertheless, in relation to a serious traffic accident, he had realized that
226
health care in the US was very expensive (his hospital bill for a week’s care was
US$32,000). Luckily, an organization that helped less privileged people paid
most of the costs, and Juliano’s car insurance covered the rest. In the quote
below, he talks about the differences between the American and Nicaraguan
health care systems, and about the need to have insurance in the US because
of the expensive care:
Juliano:
“Everything’s very expensive, but at least they don’t let you die over there [in
the US]… Everything’s much better [in US health care], the attention… But…
[…] One cannot go around [circular] without insurance… Primarily because
of that, the immigrants who don’t have documents, it’s very difficult… […] The
first thing they ask you for [when you get to the health services] is your
insurance, they say ‘Do you have insurance, papers, whatever document…’
And, if you don’t, you may have to wait for a day, two days… But, for us, no,
it’s different. We show the social security number, we show our residence
permit, the ID. It’s very expensive, it’s too costly to go to a hospital there. It’s
not like here [in Nicaragua], you can stay in a hospital and all, you can stay
there for all the time you want, and you don’t pay anything… There [in the
US], no. There, everything is money and money…”
Thus, Juliano found American health care to be of better quality, yet very
expensive, and inaccessible for those lacking residency or insurance (e.g.
undocumented migrants). On the other hand, he found Nicaraguan health
care (i.e. public hospital care) to be better compared to in America, because
everything is free. Moreover, he stressed that he was very fortunate to be a
“legal” resident in the US and to have insurance, since he knew this
enormously improved his access to health care. Juliano’s narrative is
interesting because it highlights the accessibility to health care in different
health care systems (public/private), and how (un)documentedness is key in
attaining care. It is also interesting in relation to the fact that Juliano has sent
remittances to family members for private health care, since he believes the
public care in Nicaragua to be of poor quality.
Access and undocumentedness
Regarding the international migrants, those who were undocumented had the
most difficulty accessing health care. Maribel, for example, could not access
health care in Costa Rica because of her undocumentedness. At one point she
had suffered from acute bleeding from her lower abdomen, and needed care:
Maribel:
“I was sick and… There I was without documents [anduve sin documentos], I
didn’t have a passport or anything… […] In the hospital they said ‘Your
documents, even if it’s your passport’ they said. ‘No, I don’t have it’, [I said].
‘Go and get it then [they said]…’ No, they don’t attend to us, they don’t attend
to undocumented migrants [in-documentados], they say they do but they
don’t… They send you to a health care centre, or health post. But, there they’re
227
very negligent, they don’t attend to you… I decided it was better to pay a
private clinic, but the visit and the medicines were very expensive.”
Maribel thus says that Costa Rican health care services do not attend to
undocumented immigrants, even though they officially claim they do. Instead,
those who are undocumented are sent to services with a lower quality of
services. Therefore, Maribel decided to pay out of her own pocket for private
health care, which was very costly.
Cesar describes a similar situation when he was working in Costa Rica, and
had no insurance because of his undocumentedness. He said in the interview
that on one occasion when he had been sick, he had been forced to pay for a
medicine on his own, since the health clinic would not help him without
insurance.
Cesar:
“I got sick on several occasions when I was in Costa Rica, but mostly fever,
cough. I cured myself, bought a pill, right. But, an acid we used [at work]
affected me a lot, in my eyes and my breathing, and I had to start using a spray
and I had to pay for that out of my own pocket. Because there, the clinic said
they wouldn’t help us, because we weren’t insured. It was like an underground
business… They insured the Costa Ricans [los ticos] because they were tico,
but the Nicaraguans [los nicas], no, because they were working illegally. In
Costa Rica, in order to have insurance, so that the clinic will help you with
medicine, you have to have a Costa Rican ID card [cédula tica]; otherwise you
can’t do anything.”
Cesar thus describes that the employees were treated differently by their
employer based on their nationality; the Costa Ricans received insurance
while the Nicaraguans did not, because they did not have a Costa Rican
identity card. The Nicaraguans’ undocumentedness and lack of insurance in
turn had effects on their possibilities to seek health care, and to receive the
care and medicine they needed, which is a clear case of discrimination.
In sum, this section has shown that migration events led to different effects
on the access to health care and medicine. For some, primarily the internal
migrants, the migrant’s access to health care improved after moving from a
rural to an urban area. For others, predominantly the undocumented
international migrants, the access to health care became more limited. Legal
immigration status and access to insurance were key in the process for the
international migrants. Nevertheless, for many of them, the money they made
from the migrant work could improve the access to health care for their family
members in Nicaragua, which is important to keep in mind when discussing
the effects of migration in a household perspective.
228
Next, attention will be turned to health in relation to the return phase of
migration.
Returning “home”
Davies et al. (2011) state that the health of returning migrants is complex,
because it is affected by events both during the actual migration and the
journey back home, as well as by the conditions they experience after their
return. Return migrants’ health is thus determined by a “cumulative
exposure” to risks and behaviours during the entire migration process. The
interviewees in this study experienced the process of returning home after
migration as more or less smooth, and more or less positive, for example
depending on what had motivated the migration, the surrounding
circumstances, their experiences during migration (e.g. risks, traumas), and
whether or not the migration was experienced as “successful”. In this section
I will discuss three different kinds of return experiences that produced very
different emotions.
Happy returns
Several interviewees talked about their return as a very happy event. For
example, Rosa, who had been working in Costa Rica during different periods,
had always been very happy to return home because it meant she could reunite
with her children. The last time she went to Costa Rica she had actually
returned to Nicaragua, because her longing for the children was too great to
bear (see Chapter 5). And, Fernando, whose wife was working in Spain, was
looking very forward to the day she returned, because he missed her so much
now that she was away.
Ambivalent returns
After seven years in Guatemala, Joanna had returned to her birthplace in
Cuatro Santos, where at the time of the interview she lived with her two
children in a house she and her husband had been able to acquire thanks to
the work in Guatemala. Her husband continued working as a truck driver,
travelling all over Central America, and now supported the family through his
work. Joanna dedicated her time to taking care of the children and the home.
Due to the character of her husband’s work, he only came home for short
visits; about a day every two weeks. When they had lived in Guatemala they
had seen each other much more often, which Joanna felt had been “better”.
Now, they mostly kept in touch over the phone, and Joanna said she missed
229
being closer to her husband. She did not regret the situation, though; she said
she was “happy” to have returned to Cuatro Santos, because she had
experienced great sadness being away from her home community, as well as a
fear of violence because of the gangs in Guatemala. She was also very happy
since she now lived in a house of her own, which she and her husband had
bought with the money they had made in Guatemala. At the same time, she
missed working and making money of her own, which was not possible in
Cuatro Santos because of lacking job opportunities. Her return had thus made
her less independent, and more dependent on her husband, who sent money
for the family’s sustenance; a step back in terms of gender equality, one might
say. Nevertheless, Joanna had no plans to go abroad again; travelling and
living abroad was “sad” (triste), she said, as it meant being away from your
family and your home country. Guatemala was moreover not “a country to live
in”, she continued, but only a place to work and make money in, primarily
because of all the gang-related violence and crime (por las maras). Since she
had already obtained a house of her own, Joanna reasoned that she had no
need to go abroad either. In all, Joanna’s return was filled with ambivalence,
i.e. both positive and negative emotional experiences.
“Shameful” return
For Santos, the return to León was not at all happy, but was instead
characterized by sadness and shame. He had made three attempts to go,
undocumented, to the US and to Costa Rica. In his mind all three of these
attempts to emigrate had been “unsuccessful”, since he had been caught by
the border patrol and immigration police, either when crossing the border or
after a couple of days’ stay, and deported to Nicaragua. Santos’ overall
experience of migrating was consequently rather negative. He said in the
interview that he felt ashamed at his “failure” when he returned to Nicaragua
after his migration attempts, and also that he felt alienated from his family
due to the separation. He expressed great sadness when talking about all the
difficulties he had gone through.
Santos:
“When we returned, we came with our heads down [la cabeza agachada],
without money, without anything in our pockets… […] You come back very
sorrowful [muy dolioso]…to your country, very bad…without knowing what to
do… […] You come to your country…like an emigrant again…you return to
Nicaragua like an emigrant, like a stranger… You have to adjust yourself to
your family again, because your family didn’t know you for a while.”
Santos thus expressed shame, sadness, and alienation when talking about his
return to Nicaragua. Shame and sadness are so-called negative emotions,
which may influence health negatively. Throughout our interview Santos gave
230
a very sad, almost depressed, impression, and also mentioned that he had
thought about ending his own life, and that some of his friends after
“unsuccessful” migrations had in fact committed suicide. According to several
Nicaraguan studies, suicide, or attempted suicide, among significant others is
an important factor influencing others to attempt suicide (see Obando Medina
2011; Herrera Rodríguez 2006; and Caldera Aburto 2004). However, coping
processes, when functioning well, can be enacted, and hinder the most tragic
effects of difficult life experiences. For Santos, talking about his sufferings was
important, and he had also written about his migration attempts to the US in
a short story entitled “The Five Friends” (Los Cinco Amigos). That Santos both
talked and wrote about his sufferings might thus be seen as a way of coping
with what he had gone through. Storytelling may indeed have a
healing/therapeutic effect, and can also be beneficial for health (Pennebaker
e.g. 1995). “Whether in written or spoken form, putting personal experiences
into a story is associated with both physical and mental benefits across diverse
samples” (Pennebaker & Seagal 1999: 1252) (see also e.g. Rosenthal 2003).
In this section I have shown how return was experienced emotionally by some
of the interviewees. I agree with Davies et al. (2011) that the health of
returning migrants is complex, because it is affected by the whole migration
process, i.e. events not only before and during but also after the actual
migration. In this study the circumstances surrounding migration events
seemed highly influential in how the return was experienced by the migrant,
and in the consequences on health. The interviews showed that the process of
return may have various emotional impacts; for example, positive
psychological effects (decreased worry, stress, sadness, or happiness) or
negative effects (shame, alienation, depression), which, according to
mind/body medicine and the theories on emotions and health, may influence
both physical and mental health.
Next, I will present results of the survey study concerning opinions about the
situation of emigrated Nicaraguans in terms of work, studies, housing, health,
and social life. These findings may add to the understanding of how life is
experienced by Nicaraguans abroad.
Results of the survey study: the migrants’ situation abroad
In the survey, we asked the respondents about their opinions regarding
emigrated Nicaraguans’ living conditions in the new country164. In this
164 Questions 21-23; p. 5 in questionnaire (see Appendix). The respondent was asked to rate the emigrant’s (i.e.
partners, children, and Nicaraguans in general) situation in relation to five areas: work, study, housing, health
and social life. The reply options for Questions 21-22 (concerning partners and children) were: good, regular,
231
section, I will show results concerning parents’ opinions about their children’s
situation abroad, and all respondents’ opinions concerning the living
conditions of Nicaraguan emigrants in general.
About 25% of the respondents had children living in other places, of whom
four-fifths lived abroad. Almost two-thirds (64%) of the respondents reported
that they had children whose living conditions were “good” (regarding the
areas: work, study housing, health and social life). However, a quarter (25%)
of the respondents said they had children who endured “bad” living
conditions. Moreover, about half (47%) of the emigrated children had no
family members living close by, which may indicate social isolation or a lack
of family support.
Concerning the respondents’ opinions about the situation for exiled
Nicaraguans in general, most rated it as better or the same as in Nicaragua.
Regarding work, 76% of the respondents answered that the situation for exiled
Nicaraguans was better or the same, while for housing, 36% replied that it was
worse. Regarding health, 64% believed it was better/the same, and 26% that
it was worse.
It is difficult to draw any broader conclusions from these findings, but they
nevertheless indicate what people think about their family members’
experiences of migration, as well as about the situation for emigrated
Nicaraguans, which may influence the health and well-being of those left
behind as well as future migrations. Even though the majority believed their
children lived good lives abroad, a large part had children who lived under bad
conditions, which may cause worry and stress for these parents. Moreover, the
majority believed that Nicaraguan emigrants generally lived under similar or
better living conditions, which can be related to the general discourse that
living conditions in richer countries (e.g. the US) are much better than in
poorer ones (e.g. Nicaragua). However, many believed that the housing
situation was worse for exiled Nicaraguans, and also that the social and health
situation was worse, which was also illustrated in the qualitative interviews.
Summary and conclusions
This chapter has examined health consequences for the migrant during the
migration process. I have followed the migrants along their path – during their
travel, at their destination, and after their return home.
bad, don’t know, not applicable; and for Question 23 (concerning Nicaraguans in general): better, the same,
worse, don’t know. The results of Question 21 are not presented here, as very few respondents reported having
their partner living abroad.
232
The chapter has shown that both internal and international migrants may be
vulnerable to risks and experience hard times in order to reach their
destination. The undocumented international migrants were particularly
vulnerable and exposed to high risks during border crossings. Borders are
indeed often dangerous settings, and the chapter showed how migrants can
suffer both physically and mentally during the journey. Even though crossing
the American border caused the most perilous situations, the Costa Rican
border was also stressful to cross without documents. The migrants who could
cross borders legally were in a much less vulnerable situation, and usually
experienced much less stress. In all, (un)documentedness was key in how the
journey was experienced.
At the destination the migrants’ health was affected in a variety of ways, both
positively and negatively. Some experienced positive changes to their social
milieus in relation to migration events (e.g. an end to physical and sexual
abuse, and gaining new, more supportive relationships). And, some learnt new
skills after their migration, which may indirectly affect health positively.
However, the new environment most often created stress, in relation to the
disruptions in the individual’s life space (i.e. processes of estrangement and
cultural bereavement), which took the form of homesickness and bodily
discomfort (health problems due to, for example, climate change). It also led
to stress due to “othering” and racism, for example discrimination,
maltreatment, physical and mental abuse. Furthermore, many international
migrants, especially those who were undocumented, faced precarious working
and living conditions, which caused vulnerability and stress. Precarious work
may have detrimental effects on health, and the rightless situation many
undocumented workers were in also often produced negative effects on health
and the access to health care. Those who did not experience such negative
effects often worked “legally”, or in jobs that were “invisible” from public view
(e.g. the migrant who was able to stay overnight at the workplace). Access to
health care often also changed, for the better or for the worse, depending on
the context. Internal migrants often gained better access when moving to
urban areas, while international migrants, especially those who were
undocumented, often experienced limitations in the access to health care.
Legal immigration status and insurance were decisive in this process. The
chapter also showed that different strategies were used to cope with the
difficulties migration gave rise to – both of a more negative kind (e.g.
worrying), and of a more positive kind (e.g. expressing faith).
The chapter also highlighted how migrants experienced their return,
especially its emotional impacts. Primarily three types of returns were
identified in the interviews – those experienced as happy, ambivalent, or
shameful. Return migrants’ health is an under-researched area, but existing
233
evidence shows that health after return is determined by the conditions during
the entire process of migration.
One of the main findings in the chapter was the importance of social
differences. Migration puts many of those involved in a situation characterized
by vulnerability and suffering. Nevertheless, the degree and significance of the
vulnerability and suffering varied a great deal depending on the personal
context. The interviewees with experience of undocumented migration –
either from having performed irregular moves themselves, or from being the
family member of an undocumented migrant – often described more urgent
situations of vulnerability; hence, undocumentedness was an important factor
in how the consequences of migration took shape – and consequently in
migration’s implications on health. The issue of social differences was also
highlighted in other ways. For example, skin colour was of importance in the
sense that those with paler skin experienced less “othering”, and consequently
also endured less stress, than did those with darker skin. The issue of social
class was also discussed; migrants who moved from the countryside to town
sometimes felt unskilled and occasionally degraded by the richer people in
town. Overall the study has shown a varied, albeit stratified, pattern of
migration-health relations for the migrant.
Findings of the survey study showed, furthermore, that the general opinion
about living conditions for emigrated Nicaraguans was that they lived good
lives, or similar/better lives than in Nicaragua, which can be placed in relation
to the common discourse on migration to richer countries, where migrants are
assumed to live better lives. This discourse may also influence future
migrations. However, many believed that their emigrated family members
endured bad living conditions, which may negatively influence the leftbehinds’ mental health.
In the next chapter, attention will be turned to how social relations
(particularly family relations) changed in connection to migration, and how
they influenced the study participants’ lives and health.
234
CHAPTER SEVEN
Coping with translocal lives
Introduction
This chapter focuses on migration-induced changes in social relations,
particularly family relations, and thus deals with the “translocal lives” that
arise when social relations become spatially stretched out due to migration.
The chapter highlights the direct and indirect consequences of migration on
the relations between the migrants and their left-behind family members who
participated in this study, and discusses the health implications of these
changes. Like the previous chapter, this chapter is related to the third research
question of the thesis; more specifically to the two sub-questions: How do
different kinds of migration experiences affect the migrant, and how do they
affect the family members of migrants (e.g. socially, economically,
healthwise, and emotionally)? The chapter will respond to how the study
participants’ social relations are affected by migration events, what positive
and negative effects these changes have on health and on the access to health
care and medicine, as well as how the study participants cope with the changes
in social relations that migration causes (the “translocal lives”). Moreover,
vulnerability and suffering are discussed throughout the chapter, since they
were important for both the migrants’ and the left-behinds’ experience of
migration and its effects on social relations.
Similarly to the two previous empirical chapters, this chapter is based on the
understanding that migration and health are connected in complex and
multiple ways – migration has manifold effects on health at the same time as
health has diverse effects on migration. Like Chapter 6, the present chapter
scrutinizes the ways that migration affects health (MH), but with focus on
how social relations, particularly family relations, are affected. Based on the
understanding that migration is of a processual nature, encompassing
different phases and linking different places – as described earlier – the
chapter takes into account the entire process of migration, but focuses
primarily on the social linkage between places, including conditions in the
origin, during travel and at the destination. The theme of this chapter relates
to the body of literature that researches the links between family and
migration – through concepts such as the “transnational family”, the
“translocal family” and the “left-behind family” (see e.g. Hondagneu-Sotelo &
235
Avila 1997; Pribilsky 2004; Yeoh et al. 2002, 2005; Parreñas 2001, 2002,
2005; Toyota, Yeoh & Nguyen 2007; Tan & Yeoh 2011).
The chapter uses both interview and survey data and is divided into two main
sections, which stem from two important themes identified in the qualitative
analysis. The first section, divided families, focuses on the interviewees’
experiences of the separation between family members that migration causes,
and the changes to and consequences on, for example, family relations and
health. The survey data in this section investigate associations between
migration and self-rated health, in order to assess whether there were any
differences in health between respondents who belonged to migrant and nonmigrant families respectively. The second section, parenting and caring at a
distance – tensions and coping strategies, gives attention to the ways the
interviewees handled/coped with the translocal lives, and how practices of
care were entangled in these coping processes. Survey data on the contact
within transnational social spaces are also presented in this section. A
summary of the chapter’s findings is presented last.
Divided families
I have previously shown how Nicaraguan migration is often embedded in the
strategies of making a living; i.e. a practice of mobile livelihoods. Since mobile
livelihoods most often take place within the realms of households, they
consequently often entail separation between family members. Even though
families are divided due to the practice of mobile livelihoods, family members
do, however, often maintain relations in different ways. This gives rise to
“translocal geographies” (Brickell & Datta 2011), which entail a “simultaneous
situatedness across different locales” (ibid. p. 4). The concept of translocal
geographies extends the transnational and translocality frameworks by
emphazizing how spaces and places are both situated and connected to a
variety of locales. It thus provides a framework for analysing the geographies
of everyday lives across spaces, places and scales.
Translocal geographies resonates with the concept of “transnational social
spaces” (e.g. Faist 2000). Thomas Faist (2000) describes transnational social
spaces as sustained social and symbolic ties within networks in multiple
nation states. Transnational social spaces consist of dynamic cultural, political
and economic processes, Faist continues, and include both migrants and nonmigrants in an informal or a more institutionalized way. One form of
transnational social spaces are transnational kinship groups, which are
typically exemplified by multi-local households, i.e. “transnational families”,
that maintain (strong) social ties regardless of the distance. Transnational
236
kinship groups are characterized by a high degree of reciprocity (mutual
exchange/dependence), for instance seen in the practice of sending and
receiving remittances. According to Baldassar & Merla (2013), transnational
families are a particular type of family form, which is characterized by their
members “continu[ing] to feel they ‘belong’ to a family even though they may
not see each other or be physically co-present often or for extended periods of
time” (p. 6). Despite being separated over time and space, they maintain a
sense of “family-hood” (Bryceson & Vuorela 2002, in Baldassar & Merla
2013), through a range of different strategies (ibid.; see also Schmalzbauer
2008).
One central aspect in the research on transnational families is familial
separation. Research shows that separation from family may induce great
stress and affect the emotional well-being, and sometimes even cause
depression, for both migrants and their family members who remain in their
countries of origin (e.g. Silver 2011, with reference to Aguilera-Guzman et al.
2004; Aroian & Norris 2003; Espin 1987, 1999). One important reason for
this, according to Silver (2011), is that migration involves a strain on the
support networks of both migrants and their family members, sometimes even
leading to the breakdown of social support. This might thus cause stress in the
individual, since social support, particularly that stemming from close
relationships (e.g. spousal and parent-child relations), is an important buffer
against mental distress, as mentioned earlier (see also e.g. Thoits 1995).
Consequently, research shows that spouses and children are particularly
affected by family separation due to migration (Silver 2011, with reference to
e.g. Rodriguez et al. 2000, Aguilera-Guzman et al. 2004, and Aroian & Norris
2003). In a study on Mexican migrant families, Silver (2011) shows that the
migration of close family members to the US (especially that of spouses and
children) increases depressive symptoms and feelings of loneliness among the
remaining family members in Mexico (particularly among wives and
mothers). Parreñas (2001, 2002, 2005) also emphasizes the pain of family
separation in her studies on migrant Filipina domestic workers, and Pribilsky
(2004) relates that the most difficult thing his male Ecuadorian migrant
informants in New York experienced was maintaining conjugal relations (see
also e.g. Boehm 2011). Schmalzbauer (2004), in a study on Honduran
transnational families, also shows that stress resulting from familial
separation was common, regardless of the strategies employed to sustain
relations (e.g. communication). Her informants talked about missing their
loved ones, and some also expressed feeling deserted or undervalued by their
migrant family members. At the same time, though, they also spoke of
benefitting from the remittances sent back to them. Baldassar (2008) relates
that one of the key emotions the Italian transnational migrants in her study
expressed was a sense of longing, particularly for family members but also for
237
place (i.e. the origin). Nicholson (2006) also discusses the high emotional
costs Latin American immigrant women in the US experience due to their
absence from their children, and that “the arduous journey, the hard work and
isolation experienced once in the United States, and the years spent away from
their children — point to a good deal of suffering on the part of these mothers”
(ibid. p. 30). In Svaŝek (2008), the emotional dynamics of transnational
family life (and migrant belonging) are also highlighted. Besides more
negative feelings of loss, disorientation, anger, homesickness and guilt, more
positive feelings were also visible in interviews, such as expressions of love
and care. Hence, Svaŝek concludes that “the emotional life of migrants is often
characterised by contradiction” (ibid. p. 216). Similarly, Baldassar (2007)
shows how both migrants and left-behinds are involved in the difficult
emotional task of managing “truth and distance” – thereby sometimes
concealing information they expect will provoke worry, for example regarding
illness.
Besides causing immediate stress upon separation, the diminished support
networks may also cause more difficulties in coping with, for example, daily
life stressors. And, differences in access to resources and decision-making
between family members may arise, for example, which can cause stress for
both the migrants and the family members left behind (Silver 2011).
Moreover, if the family member(s) who remain in the origin become
dependent on the remittances sent from abroad, and if the migrant(s) come to
be out of work or abandon the family, a difficult economic situation may arise
(the migrants may themselves also, of course, be under a great deal of stress
knowing that the family back home is in need of their support). Problems can
also arise in relation to the authority to decide how remittances should be used
(which is often biased towards the receiving party) (see e.g. Pribilsky 2004).
The difficulties of separation are perhaps felt even more when migration is
undertaken irregularly, since it might lead to entrapment in the destination
country (as mentioned earlier). As Khosravi (2011: 22) writes, “[s]eparation
from family is an expected consequence of migration, and irregular migration
puts enormous distance between family members extended across time and
space. Migration without documents is a one-way road, and there is no turning
back once you step onto it”. In relation to this, Cecilia Menjívar (2012)
discusses how the dynamics of parenting across borders are shaped by legal
aspects, and that parental relationships and obligations are strongly
influenced by legal constraints.
The separation within transnational families does not always cause emotional
pain or stress, of course. Some may experience the separation as providing
new opportunities, independence and empowerment (e.g. Silver 2011).
238
Emotional impacts of separation
Most of the interviewees in this study had experience of living – or having
lived – separated from family members. One important result from the
qualitative interview study was how emotionally affected the interviewees
were by migration events and the translocal lives they were leading. As in the
literature on transnational families and separation, described above, the
interviewees expressed both positive and negative emotions – either directly
or indirectly – when talking about their lives and migration. Many expressed
positive emotions, such as feelings of joy (e.g. happiness, pride, hope,
relief/liberation, and empowerment) and of love, in terms of showing how
they longed and cared for their loved ones. Many also expressed negative
emotions, such as sadness (e.g. loneliness, homesickness, despair,
hopelessness, suffering, uncertainty, shame at failure, humiliation, and stress)
and fear, in terms of worry. For some, separation produced mixed, or
ambivalent, emotions.
Relief and empowerment
Marta, who presently worked as a maid in León, expressed feelings of relief
when one day her second husband unexpectedly – after 23 years of marriage
– decided to migrate to Costa Rica. Marta said in our interview that she did
not care at all when he left, since he had beat her throughout their marriage.
When he left she stopped being afraid, and also seemed to gain self-esteem,
since she started working and earning her own money again.
Marta:
“I never said to him ‘Don’t go, stay’…it was his problem…” <<C: Didn’t you
care?>> “I absolutely didn’t care… Yes, because…he’d treated me very badly…
[…] He didn’t interest me anymore, because I worked, I earned my money, my
children were already looking for work… I didn’t care anymore… Since he’d
treated me so badly… […] He’s the father of my children… for 23 years I put
up with it…the beating…mistreatment… Honestly, I was afraid of him, but I
stopped being afraid when he left. I didn’t want to continue living with him…”
Marta’s experiences are unfortunately not rare (see Chapter 5). Due to the
abuse, she expressed feelings of relief and empowerment when her husband
migrated.
In contrast to Marta, several other interviewees experienced difficulties in
relation to the separation within the family. For some, the translocal lives
entailed great mental suffering and psychological costs, and feelings of
longing, sadness and worry, for instance, were not uncommon.
239
Longing and sadness
Fernando, whose wife had been in Spain for seven months at the time of the
interview, was very troubled and sad because of the separation from his wife:
Fernando:
“When your wife goes away… It’s difficult… For me, and for my children… We
miss her so much, terribly much. I think she has problems with this too, being
there [in Spain], away… […] This troubles us, psychologically… It’s hard, we’re
not close.”
Fernando thus says that both he and the children suffered mentally because
of his wife’s absence, and also that he believed she also suffered from being
away from the family. The separation was thus psychologically hard on all
family members. Fernando was looking forward to the day his wife returned
from Spain, so that they could be together again. Upon my question about his
hopes for the future, he stressed that he hoped his children would have good
lives, and that they would not have to endure being separated from their loved
ones due to migration. Fernando communicated strong feelings when
describing the separation within the family, and was very close to tears when
talking about it. Perhaps my emotional personality or my position as an
“outsider” influenced Fernando to feel he could express himself more openly
than usual165. Or, it may be that he expressed what Salazar Torres et al. (2012)
identify as changing gender norms in Nicaraguan society, where a wider range
of masculinities are available for men to identify with. The experiences of
fathers who are left behind by their wives, and assume the responsibility over
the household and child care, which Fernando did, is an under-researched
area. Although some studies indirectly mention this in relation to mothers’
migration (e.g. Parreñas 2005; Asis et al. 2004), there are few that explicitly
study this phenomenon (see e.g. Waters 2010; Graham et al. 2012).
Maribel also expressed great sadness when talking about her migration
experiences and the separation from her children. She said that on her first
trip to Costa Rica she quickly wanted to return home because she missed her
children so much. Maribel tried her best to cope with the difficult situation, by
talking to herself about the positive side of being there.
Maribel:
“Oh…it was terrible… I just cried, I wanted to be here with my children… The
first time I went there [to Costa Rica], it came over me after 15 days, and I said
‘I’m going, I’m going [home]’… Just imagine, people assaulting you and
all…but I didn’t come home. I started to give myself therapy [terapiarme], I
said to myself ‘No, I have a good job, I have to stay’. The thought went away,
165 Diana Mulinari, who has extensive experience from Latin America, once pointed out to me that it is rather
uncommon for Latin American men to talk in such an emotional way due to the prevailing gender ideology
machismo (see Footnote 141 on Nicaraguan gender ideologies).
240
but I kept having my children in my mind [siempre andaba con la mentalidad
de mis hijos], because, well, I didn’t like having left them like that.”
Maribel’s narrative highlights several issues: firstly, the suffering she went
through because of the separation from her children. She mentions that she
was sad and longed for her children, and that she wanted to return because
she did not like the fact that she had left her children behind. This suffering
can be seen as an expression of both real pain and of what is expected of
Nicaraguan mothers due to prevailing gender norms, i.e. to be self-sacrificing
and suffering (e.g. Johansson 1999) (see Chapter 5). Secondly, it highlights
the difficulties involved with transnational parenthood, which may be
particularly hard on mothers since greater expectations are often placed on
mothers who migrate (e.g. Parreñas 2001, 2002, 2005; Hondagneu-Sotelo &
Avila 1997). Thirdly, the coping process Maribel went through was touched on
– the “self-therapy” – in which she talked to herself about the positive aspects
of being away (work and money) that made her stay in Costa Rica (see section
“Changes in family relations”). Maribel’s experiences were thus full of
contradictions and ambivalent feelings, but she stressed the emotional pain of
separation.
Gloria was also very sad because of the separation from her three sons, who
lived elsewhere (one in the south of Nicaragua and two abroad):
Gloria:
“Oh…what shall I say? I’d say that if we lived here all the time we would be bad
[have a bad life], right? […] [I]n my heart and in my mind I don’t consent to
it, right, because I suffer. I suffer, I don’t know what to say… I think about
them a lot.”
Gloria thus stressed that being separated from her sons was very painful and
that she suffered a great deal from it; she even cried when talking about it.
Despite the hardship, however, she saw the necessity of their migration in
allowing them to improve their living conditions. Gloria’s narrative included
both deep sadness and emotional distress, and, similarly to Maribel’s, also
justifications of migration as a valid strategy for the household.
Rosa was working outside León while her children stayed with her mother
about half a day’s trip from Rosa’s workplace. Due to her long working hours,
and the long distance to her mother’s place, she could only visit her children
one day a month. Previously in her life, she had also worked in Costa Rica for
both longer and shorter periods of time, while her children had stayed at home
with relatives. Towards the end of our interview, upon my question of whether
she would like to share anything else with me, Rosa told me how she had
suffered because of the separation from her children.
241
Rosa:
“The toughest thing in my life, it’s been a very hard suffering [Lo más sufrido
por parte de mi vida ha sido un sufrimiento muy duro]. Very hard for me, I
had to look for work to support them. At least, with an ache in my heart for
my children [con el dolor de mis hijos], I miss them, I wish I could be with
them. When I see my workmates go home to their houses, and I have to stay
here [at the workplace]…they’re sleeping with their children… They tell me,
‘Maybe you’ll see your children in a week’… What can I do, being so far away
from them?”
Rosa thus emphasized that the separation from her children had been very
hard and entailed great mental suffering. She mentioned how she longs for
her children, and envies her workmates who can see their children daily.
Similarly to Gloria and Maribel, her separation was justified by necessity, by
the need to look for work in order to support the children. Taken together, the
women’s stories were expressions of Nicaraguan mothering practices. The
advantages of migration did not seem to take away the pain of separation for
Rosa. Rosa’s narrative furthermore highlights that separation due to internal
migration may also be very hard for the families involved.
Worry
Worry was a recurrent theme in the interviews in relation to the separation
from family members; particularly in the interview with Cindy, who worried
both about her husband Juliano’s health and that he would be unfaithful to
her.
Cindy was 24 years old and married to Juliano, who was working in the US
(“legally”, since he had permanent residency). Cindy worried about Juliano’s
health for several reasons, and was particularly worried the time he had been
in a car accident and had to be hospitalized (see Chapter 6). For Cindy, it was
very difficult not to be at Juliano’s side and stay informed about his condition.
Cindy:
“He had a serious accident there, he was in intensive care. And I was here,
completely heartbroken, because I wanted to be at his side, I wanted to take
care of him… I felt desperate, I didn’t know what had happened to him or how
he felt. They called and said he was fine, but in fact you don’t know [when
you’re not there]… It was horrible... So because of that I tell him to be careful,
because… Well… When we say goodbye, we say ‘See you soon’, but it might be
the last time we see each other alive…”
Cindy was thus very worried and sad (“heartbroken”) at the time of Juliano’s
accident. She was in a situation in which she lacked knowledge about his
condition as well as control over the situation, which she experienced as
“horrible” and made her feel “desperate”. She continued explaining that this
242
event has made her more aware of the risks involved with being separated,
since you never know what will happen. The risk of being separated for life
(through death) because of migration is now constantly in her heart, which is
probably very stressful.
Cindy was also worried for the sake of their relationship, and feared that
Juliano would be unfaithful to her. Much of her worry was due to the stories
she often heard about emigrated men who started new families in the new
country.
Cindy:
“It’s difficult for me, because I’m alone here. Sometimes I feel like going out,
feel like being with someone who loves me… And there [in the US], he
sometimes goes out with friends, I get angry, that’s outrageous [que
barbaridad] ‘with your friends’, because sometimes he doesn’t call me, so I
get angry. How outrageous, it’s only a call, only a call, and I’m comforted [con
eso me consola]… […] Because, the truth is I’m very young, I’m 24, on par with
a lot of women whose husbands have left, and the first thing they do is find
another [woman]… I’ve behaved very well towards him. The truth is, I love
him, I love him a lot… […] Honestly, I still haven’t noticed anything… But, I
tell him, that if something were to happen, that he should protect himself, that
he doesn’t let me know, because…this is very hurtful [esa cosa duele mucho],
because I’m here waiting for him…I’m faithful to him, and…and I’m putting
all my hope on him…but… But, what will he do? Well, men are men, as they
say…”
In the quote, Cindy says she sometimes feels lonely, but that she has
nevertheless stayed faithful to Juliano. She thus portrays herself as a “good”
woman and wife who does not “run around” with other men but instead stays
at home and is faithful, as the prevailing gender norm prescribes for
Nicaraguan women (marianismo) (see Chapter 5 and Footnote 141). Cindy
also describes her fear that Juliano will be unfaithful to her, and that she is
sometimes jealous and suspicious that he is with other women in the US. Even
though she has no real grounds for these suspicions (she has not “noticed”
anything yet), her fear is based on what she knows other men have done, and
on how men are thought to behave in relation to gender norms (machismo)
and the traits of hegemonic masculinity (womanizing, in need of sexual
relations, etc.). Cindy seems very worried over this matter, and in order to
cope with this stressful situation she tries to protect herself by urging Juliano
to behave well and to protect himself if he does “do” anything (that is, that he
should use a condom if he has sex, so that he does not get anyone pregnant or
catch a disease; Cindy especially feared HIV). Cindy stresses that it would be
very painful if he were to cheat on her, since she is at home waiting for him.
She coped with this by hoping he would behave well, so that they can be
together again one day.
243
Ambivalence about migration
Many of the interviewees simultaneously expressed both positive and negative
(i.e. ambivalent) feelings about the migration experience; hence an
ambivalence about migration.
Ana, for instance, expressed relief, but also sadness and longing in relation to
her migration. She had left her family when she was 15 after a conflict within
the family due to her father having abused her sexually. Ana’s brothers blamed
her for the abuse, and when she left she was thus very relieved to escape her
brothers’ distrust and bad feelings towards her. However, Ana said she had
started missing her mother a great deal after the move:
Ana:
“When I was here…in León, I sent a card to her [her mother], to say I had
arrived, and asked her to forgive me, because I hadn’t said anything to her.
But I felt bad for what we had said, so… I thought it was better that we lived
apart, so that maybe we wouldn’t have any more problems. The… She sent for
me to apologize, then… I went to her, we forgave each other, she said I should
return, but I didn’t feel good with my brothers…they’d thrown something in
my face that I’d never done… So, I said, no, it’s better… I would make the
sacrifice to move away from my mother, right.”
Even though she was sad to leave her mother, Ana reasoned that it was a
sacrifice she had to make in order to escape the abusive family relations. This
can be seen as a way of coping with the distress she felt because of the
separation from her mother. As Ana says in the quote, she and her mother
managed to reconcile, which perhaps made Ana’s longing for her mother even
worse. In my mind, Ana placed a great deal of responsibility on herself, rather
than on her father or brothers, to solve the family situation (so that the family
would not have any more “problems”). This shows the subordinate situation
of women in Nicaragua’s patriarchal society, in which the sexual abuse of
young female family members is common (see Chapter 5). In all, Ana
expresses ambivalent emotions when talking about her experiences, both
relief at escaping abuse and mistrust as well as sadness because she missed
her mother.
Juliano, who was working in the US, very clearly showed an ambivalence in
the interview toward migration, talking about the advantages and
disadvantages of his migration:
Juliano:
“Life changes a lot… Well, look… It’s good to be there [in the US], because you
can help people [uno peude ayudar a persona] […] What it affects the most,
is the family… Luxury and things like that there, it’s not worth it… The truth
is, if you’re not together with the ones you want to be with and share it… […]
I’d be happy if my wife and my son could come there… There everything is
244
different, when you get home from work the house is empty, there’s no one
who says ‘How have you been’… I miss that a lot when I go… […] Everyone
wants to go to another country, maybe for the [economic] conditions, but
when you’re there, it’s another thing – then the money doesn’t matter any
longer, what interests you is the family…to be here. […] As I say, there are
advantages and disadvantages… I would be a liar if I didn’t say I missed this
country, being here with the family…”
Juliano thus says that the money he makes in the US is good, since it improves
the living conditions for his close and extended family in Nicaragua. Juliano
and Cindy’s economic situation had in fact improved greatly, thanks to the
money Juliano was making in the US. He also mentions that he enjoys the
higher standard of living in the US. These economic gains were clearly the
greatest advantage of his migration, he said. However, at the same time, he
did not feel he could fully enjoy the better living conditions (the “luxury”) in
the US while living there on his own. He says he feels lonely, and that he
misses his family and living with family, as well as Nicaragua in general. The
separation from his family, and the psychological cost it entailed, was
undoubtedly the greatest disadvantage of his migration, and the hardest to
bear. He wondered whether the money he was making was actually worth the
hurt and longing that the separation from his loved ones caused. He thus
seems to experience highly ambivalent feelings towards his migration.
Juliano’s wife Cindy similarly expressed that Juliano’s migration entailed
difficulties, but at the same time was necessary for the sake of their future.
Cindy:
“When he left…it was…difficult for the family, because… Well, we’re used to
living together. But…we knew that in order for us to have a better life he had
to emigrate… […] Yes, it’s very difficult, because to be alone here, because
sometimes you can’t have it all… But, if you’re with your partner, you’re
suffering economically and all that, and if you have money, you can’t be close
to the one you love [si tienes todo económico no podes tener el aspecto que
voz queres]…”
In the quote, Cindy stresses that Juliano’s migration has been hard on them
as a family, and that one consequence is that she feels lonely. At the same time,
she understands that they cannot be together if they want to improve their
living conditions. She underscores that it is a choice you have to make – be
together with the one you love but suffer economically, or improve the
household economy but suffer psychologically due to separation. Juliano’s
migration thus caused highly ambivalent feelings for Cindy.
Both Juliano and Cindy expressed that there were both advantages and
disadvantages involved with his migration, which seemed to cause ambivalent
feelings for them. The major conflict in their lives was between working in
245
order to make money and get what they needed and wanted in life, and
enduring family separation due to migration. In Juliano and Cindy’s case
there was thus an apparent family-work conflict.
This section has shown that the emotional impacts of separation due to
migration may be very varied, ranging from positive to negative feelings, and
also involving an ambivalence about migration. Next, attention is turned to
the changes in family relations that migration may cause and the effects of
these changes on health.
Changes in family relations
The literature points to the notion that the family undergoes fundamental
transformations in relation to transnational migration. New familial relations,
new roles, and additional responsibilities, for example, must be adapted to,
and these changes may be an important source of stress for both the migrants
and the family members they have left behind (e.g. Silver 2011; Schmalzbauer
2004; Pribilsky 2004). The issue of parenthood has received a great deal of
attention in the literature, since parent-child relations are fundamentally
changed in cases in which parents migrate and children are left behind in the
origin (see e.g. Carling, Menjívar & Schmalzbauer 2012; Schmalzbauer 2010).
A new form of “transnational parenthood” has consequently arisen, in which
the “parent-child relationship is practised and experienced within the
constraints of physical separation” (Carling, Menjívar & Schmalzbauer 2012:
192). As parenting roles are commonly gendered (performed in different ways
by men and women, respectively), transnational parenthood is also “affected
in gender-specific ways” (ibid. p. 192), both for the mothers and fathers who
stay and for those who migrate. This may create tensions in traditional gender
relations, and the changes may sometimes be difficult to adapt to. An example
of this is when mothers migrate, leaving their children in the care of others to
assume a breadwinning role (and at the same time must rely on the new
caregivers to provide for their children); or when fathers migrate, and the leftbehind mothers may have to take on additional responsibilities in terms of
discipline and decision-making, which some may experience as overwhelming
while others may find it empowering. Additionally, they may have to help their
children cope with paternal absence (Carling, Menjívar & Schmalzbauer 2012;
Silver 2011).
Even though both migrating mothers and fathers perform similar
transnational parenting activities – for example, sending money and gifts, and
maintaining communication – many studies show that greater expectations
are often placed on mothers who migrate, and that migrating mothers
246
continue to be responsible for the emotional care of children (see e.g. Parreñas
2001, 2002, 2005; and Hondagneu-Sotelo & Avila 1997). Transnational
mothers consequently often continue to carry out the act of mothering, but
from afar, which may be a difficult and stressful experience. In a study on
Central American female migrants in Los Angeles, USA, Hondagneu-Sotelo
and Avila (1997) introduced the concept of “transnational motherhood” to
characterize this new form of mothering. They state that being a transnational
mother not only involves being physically separated from one’s children, but
also means “forsaking deeply felt beliefs that biological mothers should raise
their own children, and replacing that belief with new definitions of
motherhood” (ibid. p. 557). Transnational mothering thus includes “a
reconstitution of gender and mothering to include breadwinning when
performing it from a distance” (Parreñas 2008: 1058). In the case of Latin
American female migrants, however, Hondagneu-Sotelo and Avila (1997)
argue that the transition to transnational motherhood might be facilitated by
the “collectivist” approach to mothering (shared mothering) that is common
in Latin America, involving a reliance on other, primarily female, caregivers
(e.g. grandmothers, “godmothers”/comadres, aunts, etc.), as well as the
children’s fathers. In this context, as in other Third World societies, economic
conditions indeed often necessitate the sharing of child-rearing
responsibilities with others, preferably family members (Nicholson 2006).
Nanneke Winters (2014), for example, shows how practices of “translocal
carework” (with a focus on childcare) among rural Nicaraguans are in play and
shape mobility and livelihood patterns. Michele Nicholson (2006) argues that
mothers who migrate choose – along with their partners and close relatives –
a transnational strategy for shared mothering, because they believe that
migration will improve the overall welfare of the family. However, it is a
particularly difficult form of shared mothering.
Transnational fathers and fathering have not received as much attention in
the literature as have transnational mothers and mothering (Parreñas 2008).
According to Parreñas, this is probably because fathers’ absence due to
migration is more consistent with traditional gender norms (e.g. male
breadwinning), and therefore does not reconstitute the gender behaviour in
the family. Consequently, transnational fathers often fall back on “a
heightened version of conventional fathering” (ibid. p. 1058), through the
display of authority and by disciplining children from afar. Furthermore, as
Carling, Menjívar and Schmalzbauer (2012) write, it is not uncommon for
fathers to circumvent gender expectations, for instance through abandoning
their families back home. The reasons for this are varied, according to the
authors. For some, abandonment might be a coping strategy, used when
difficulties arise during migrant life and separation from loved ones, and
possibly in relation to an inability to live up to expectations (migrant men
247
commonly use more self-destructive coping strategies when facing distress,
such as alcohol consumption; ibid.). Even though there is a lack of research
on the emotions of transnational fathers, this group certainly also suffers due
to family separation (see e.g. Montes 2013, with reference to Dreby 2010;
Pinedo Turnovsky 2006; Pribilsky 2004). For example, in studies on Central
American migrant fathers in the US, Schmalzbauer (e.g. 2013) has shown that
the fathers experienced loneliness and depression. Pribilsky (2004) presents
similar results in relation to Ecuadorian migrant fathers, and found that
suffering was a reason for abandonment in some cases. Montes (2013) reveals
that Guatemalan migrant fathers express not only love and sacrifice but also
fear in relation to their connections to their families, especially their children.
These emotional expressions are in stark contrast to the culturally expected
hegemonic masculinity (cf. Connell 1995). Other studies do not reveal the
emotional labour transnational fathers undertake but instead stress other
aspects of fathering, such as a commitment to (providing for) the family,
showing authority and disciplining from afar (Schmalzbauer 2013).
Bustamente and Alemán (2007) present a more complex picture of
transnational fatherhood, in a study on Mexican migrant workers in the US.
They show that transnational fathers use different types of strategies to
exercise fatherhood and sustain family relations, including providing for the
family (through working hard, and sending money as well as gifts) and
communicating with the family (through phone calls, letters, and photos). The
authors conclude that communication is used for raising children and
discussing the use of money with one’s wife, but most importantly, it is a
means for coping with the emotional strain of family separation, since the
transnational fathers experience great loneliness, longing and guilt, and try
their best to avoid the stigma of being regarded as “bad” fathers. Another
aspect concerning fatherhood and migration that has received little attention
in research is the experience of fathers who are left behind by their wives (e.g.
Parreñas 2005; Asis et al. 2004; Waters 2010; Graham et al. 2012).
In relation to children who are separated from their parents, Suárez‐Orozco,
Todorova and Louie (2002) write that the literature points to a negative
experience for children, both during the time when their parents are gone and
when/if reunification takes place. Studies report, for example, feelings of
abandonment, detachment, reproach, estrangement, and longing. The
authors explain the negative effects on children by use of several different
psychological theories on child development; for example, “object relations
theories” and “early attachment theories”, which state that early relationships
and early attachments (for instance between mother and child) are
particularly important for later development and well-being (it is thus argued
that disruptions in important relationships, for example through migration,
may cause sadness and a sense of loss). In the context of shared mothering,
248
however, the Western focus on the mother-child dyad in these theories may
be problematic (ibid.), and perhaps not as relevant. The literature on
experiences of loss may instead be more applicable. Suárez‐Orozco, Todorova
and Louie (2002) explain that loss, stemming from either death or other
“exits” such as migration, usually sets off adaption processes, involving
physical, emotional and behavioural responses (e.g. grief). “Ambiguous loss”
(cf. Boss 1999) is, furthermore, highly relevant in the case of parent-child
separation due to migration, with the child often forced to handle a situation
in which the parent is both away and present (for instance, physically absent
but psychologically present). However, the need to grieve the loss of a
migrating parent is often not recognized, the authors argue, which may lead
to an entrapment of emotions and prolonged emotional effects (e.g.
depression). Therefore, Suárez‐Orozco, Todorova and Louie (2002) conclude
that it is critical for children’s well-being to maintain relations with their
missing parents. Graham et al. (2012) similarly argue that the contact between
children and their migrating, as well as non-migrating, parents may be highly
important for the left-behind children’s subjective well-being.
Several of the interviewees in this study said that family relations had changed
due to migration. In this section, I will dissuss three aspects of changes in
family relations that I identified as particularly salient in the in-depth
interviews: abandonment; the tensions of parenting at a distance
(transnational motherhood); and the concerns about children’s health as a
consequence of changing parent-child relations.
Abandonment
As shown previously, Marta welcomed her husband’s migration to Costa Rica,
since he had physically abused her for many years. Nonetheless, she was very
upset at first because he had taken another woman with him to Costa Rica,
and subsequently abandoned Marta and the children altogether.
Marta:
“But, he took another [woman] with him, a woman he was seeing… And that
was the problem, he didn’t send us any money… […] He called me on the
phone, but it was to discuss, to fight, you understand? So, I said to myself, no.”
Marta’s story shows the effects of the patriarchal Nicaraguan society, which
often entails women being left with all the responsibility for their children if
the father decides to leave, since they are generally regarded as the children’s
primary carers. Marta’s husband stayed in touch for a short time after his
departure but did not send any money, and only caused distress for Marta by
arguing on the phone. She therefore decided it would be better to not have him
in her life at all. Even though she was very upset over her husband’s behaviour
249
at first, her anger was soon replaced by feelings of relief and empowerment as
the physical abuse had come to an end, and as she started to make a living on
her own again.
Like Marta, Rosa had also been abandoned, although Rosa had suffered more
from it than Marta had. After the death of Rosa’s first husband, she and her
two young children had lived for two years in a provisional humanitarian
settlement (after Hurricane Mitch). It was towards the end of these difficult
years that she met her second husband, with whom she had her third child. A
year and a half later, the husband left for Costa Rica (in order to improve their
economic conditions). Although he promised not to “forget” her and their son,
three years passed without much notice from him. The following is how Rosa
described these events:
Rosa:
“I was quite young, I was only 19, I was a young woman. This guy came along,
we fell in love... I got pregnant, it was my third child. When we’d been together
two years, he said he was going to go to Costa Rica, but that he wouldn’t forget,
that he would remember he had a child. My boy was about 18 months then,
when this happened. One time he remembered the boy and sent me [money].
Then he didn’t send me anything for like three years; three years went by
without him sending anything for the boy. […] For three years I didn’t know
anything about him, and he didn’t know anything about me or the boy either.”
In the quote, Rosa describes how happy she was when she met her second
husband and had her third child, but that this happiness was replaced by
feelings of resentment soon after he left for Costa Rica since he did not live up
to what he had promised, i.e. to not forget Rosa and the child when he moved.
He did “forget”, however, and several years passed without a word, or money,
from him. This shows again how Nicaraguan mothers are expected to be the
main providers of care for children, and that migration may lead to
abandonment.
During those silent years, when Rosa did not have any contact with, or receive
any help from, her emigrated husband, she had to find a way to support herself
and her children. As she said in the interview, she had to be both mother and
father (ser madre y padre) to the children, both provider of care and
breadwinner, thus tending to all their needs. Since no opportunities presented
themselves in Nicaragua, she felt obliged to go to Costa Rica again in order to
support her children. Rosa continued, explaining that her ex-husband had
returned about seven months prior to our interview, asking her to get back
together with him. However, she expressed feelings of resentment towards
him for having abandoned them, and especially since he had only helped out
with their son’s costs when it was convenient for him. She reasoned that it was
250
better not to have him in her life, since she did not feel she could trust him
enough. She did not want to risk being abandoned again.
For Marta and Rosa, their husbands’ migrations thus led to the abandonment
and dissolution of the family. The changes in family relations were not as
drastic for other interviewees, but it was certainly a difficult process that many
went through, as I will show in the coming pages. First, attention will be
turned to experiences of mothering at a distance.
Transnational motherhood – tensions of mothering from afar
As previously shown (pp. 240-42), Maribel and Rosa both had experiences of
leaving their children behind when they migrated, and their stories highlight
the special predicament of transnational motherhood. They suffered but
stressed that they needed to make money to support themselves and the
children. The focus on the positive aspect of migration (i.e. the breadwinning)
thus “justified” their absence, which can be seen as a way of coping with the
distress they experienced. Recall how Maribel tried her best to cope with the
difficult situation through “self-therapy”, i.e. talking to herself about the
positive side of being in Costa Rica and telling herself that she had to stay there
because she had a good job.
As mentioned above, greater expectations are often placed on mothers who
migrate, and migrating mothers often continue to be responsible for the
emotional care of their children (see e.g. Parreñas 2001, 2002, 2005; and
Hondagneu-Sotelo & Avila 1997). Even though a shared mothering is
practised (in Maribel’s and Rosa’s cases, their mothers took care of their
children), the rearrangements may still be difficult. As Nicholson (2006)
writes, “transnational mothers are living a particularly difficult form of shared
mothering, a form dictated by their arduous journeys, their long separations
from their children, and their relegation to the lowest rungs of the economic
and social ladder” (ibid. p. 14). Even though communication is maintained,
transnational mothers often express sadness, worry, hopelessness, distress,
and sometimes guilt due to their absence from their children (HondagneuSotelo & Avila 1997; Parreñas 2001, 2002, 2005). If transnational mothers are
confident of their children’s well-being, however, it may be easier for them to
focus on breadwinning, which then may be considered “a valid form of
caregiving, although from a distance” (ibid. p. 29).
One might say that Maribel managed to see breadwinning as a legitimate form
of caring, albeit from a distance, which lessened her suffering a bit. However,
for Rosa it did not seem that the breadwinning aspect of parenting eased the
pain of being separated from her children.
251
Consequences on parent-child relations and child health
In cases when fathers migrated, difficulties arose in family relations. Cindy
said in the interview that her husband Juliano’s absence had affected their
family relations a great deal, particularly in relation to their son’s upbringing.
The boy was just two years old when Juliano left for the US for the first time.
Cindy:
“What affects me is that we’re not together… Maybe that he’s missed out on
seeing the boy grow up, seeing the good things the child has gone through, the
good and the bad things, seeing when he has grown. […] The boy was very little
when Juliano left, so he was raised by me. He doesn’t obey his father, he only
does what I tell him, because he sees his father like someone who gives him
everything he wants, like toys, money…everything he wants. And, his father
doesn’t like to tell him off either, to say anything to him, because he thinks the
boy will be angry with him forever.”
For Cindy, one of the most difficult things about being separated from Juliano
was thus that he had not been present during their son’s childhood, and had
therefore missed seeing what the boy had gone through while growing up.
Another difficulty Cindy mentions in the quote is that Juliano had not been
there to raise their son, but that she had done it all by herself. One effect of
this was that the relationship between Juliano and his son had changed
drastically, so that Juliano was no longer a father to his son, able to correct
him when necessary (as Juliano feared he would lose his son’s affection).
Instead, Juliano had become someone who was occasionally there to “spoil”
him (e.g. give him presents). The parent-child relations in Juliano and Cindy’s
family had thus undergone great changes due to Juliano’s migration.
Cindy also said that Juliano’s absence had been extremely hard on their son
because he was very close to Juliano, or at least had been before he had left.
Cindy described that the boy had stopped eating normally and that he slept
poorly, and also that he had been very sad from the onset and, indeed, still
was. With help from the school psychologist, and through adaptation over
time, the situation had nevertheless slightly improved.
Cindy:
“The boy suffered a lot, because…he’s very close to his father. He went through
a lot of changes…he stopped drinking milk…and he cried a lot… […] And, he
slept bad… Well, at school they took him to the psychologist, because he was
crying in school, he wanted his Daddy, he wanted his Daddy to come get him,
he didn’t want his Daddy to be away… So, he had a lot of problems. Well, that
affected me too, seeing him like that and knowing I couldn’t do anything. […]
Sometimes he couldn’t stop crying. He saw the psychologist at school, they
were treating him. Yes, he was affected a lot. Well, when he was smaller… I
would say that, maybe now that he’s older, maybe this affects him less.
Children adjust, they get used to seeing their father come and go.”
252
Cindy thus says that her son had suffered a great deal emotionally due to the
separation from his father, which had affected his eating and sleeping habits,
and made him very sad. The son’s sufferings also affected Cindy negatively;
she felt helpless, because she could not do anything to improve the situation
for her son. It was thus difficult for Cindy to help her son to cope with his
father’s absence, which previous studies also have shown to be the case (e.g.
Carling, Menjívar & Schmalzbauer 2012). Luckily, the boy received
counselling from the school psychologist, which improved the situation
slightly. Nevertheless, Cindy states that time has played the most important
role in the boy’s adjustment to the situation.
Rosa, who had been separated from her children on many occasions due to
her migrations, and had been abandoned by her second husband when he
went abroad, mentioned several aspects of how the family relations had
changed and suffered because of migration. For example, she said her children
now saw her more as a sister than a mother, because of her absence.
Rosa:
“My mother’s the one who corrects them; they see me like a sister, they respect
me but they see my mother as their mother. She’s the one who takes them to
the clinic when they’re sick; I can buy them medicine, but she’s the one who
gives it to them.”
Since Rosa’s mother had taken care of Rosa’s children for so long, they had
thus started to see her as their mother. She is the one who has raised them for
the most part (she “corrects them”), and takes care of their health needs (takes
them to the doctor, gives them medicine). Through her absence, Rosa’s role as
a parent has more become that of the breadwinner, the one who provides
money for their sustenance, but it is her mother who has come to assume the
role of mother, raising them and taking care of them. Rosa spoke about the
matter with a sad tone in her voice.
Rosa also mentioned in the interview that her youngest son had become ill
because of Rosa and her ex-husband’s absence. The last time she had been to
Costa Rica the boy had suffered an ear infection, which went untreated and
eventually caused serious damage to his hearing. In Rosa’s mind, it was the
boy’s caretakers’ (Rosa’s relatives) neglect that had caused this long-term
health problem. The boy had also been depressed, and suffered from heart
problems. Rosa reasoned that it was the separation from her and the boy’s
father – due to his abandonment – that caused both the sickliness and the
depression, but that the boy’s health problems were aggravated by the
relative’s neglect and maltreatment while she was away.
253
Rosa:
“The last time I went to Costa Rica, my son got sick. He had a bad ear infection,
and needed expensive exams. I told the doctor I was poor, that I was both
mother and father [padre y madre] to them, and that I couldn’t afford the
treatment. He couldn’t speak properly so he was sent to a clinic for
handicapped children [los Pipitos, León]. […] He had a depression when I got
back from Costa Rica, on account of having missed me. He was used to seeing
his Mummy and Daddy, and he [the father] was not there either. He had a bad
depression. […] They say that when he had this depression, they say he was
thinking a lot about his Daddy, he said ‘He doesn’t like me’, because he saw
how other children got attention from their parents [sus papas les dan
caricias]. But his father didn’t give him anything [no le daba cariño], I had to
work to give him the things [cariño] he needed. The doctor said the boy had
said ‘My daddy doesn’t love me because he doesn’t give me things [no me hace
caricias], and from this thinking came this heartache. One day he couldn’t
even walk. […] Living in the house were my sister, my brother and his wife,
and my mother, who lived with a man. They ignored my children… They were
rude to them [le hacían grosería]… My sister didn’t look after the children… I
suffered a lot, I came back from working hard, for their best, I wanted to
provide food for them, that they didn’t lack anything, that they could study…
I killed myself working for them… It turned out that my sister-in-law, who has
never been nice to me, was rude to my children. […] When I got back he [the
youngest son] cried after me, because he didn’t want me to leave, but I had to
work in order to feed them.”
As Rosa says in the quote, the boy’s ear infection was severe when she returned
from Costa Rica, and he needed to go through several examinations that were
unfortunately too expensive for her to afford since she was the sole provider
for her children (padre y madre). The treatment was furthermore delayed due
to the caretakers’ neglect while Rosa was away, which caused permanent
damage to his hearing and ability to speak, and he therefore needed
rehabilitation (which was free, although the cost of travelling to the rehab
centre in León was taxing on Rosa’s economy). The boy had also suffered a
great deal emotionally due to being separated from Rosa, and because of his
father’s abandonment. Rosa seemed to blame her family, who were supposed
to take care of the boy and his siblings, for not caring enough about him. She
also believed that members of her family had treated the boy badly, which had
aggravated his emotional distress. She also underscored that it was
disheartening for her to return from working hard for the sake of her children
and to find the boy in this poor condition.
Hence, since Rosa was a single mother, with sole responsibility for her
children – due to the death of her first husband and the abandonment of her
second husband – she had been obliged to migrate in order to find work and
be able to support herself and her three children. As a consequence, her
relationship with her children had changed, and at the time of the interview
she was more like a sister to them than a mother. The relatives Rosa had
entrusted to take care of her children during her last migration to Costa Rica
254
had not treated them well, and her youngest son had suffered both physically
and mentally from neglect. This probably affected Rosa’s possibilities to focus
on the breadwinning aspect of parenting.
Both Cindy’s and Rosa’s stories show how the changes in parent-child
relations that migration causes may have great consequences on child health.
As Suárez‐Orozco, Todorova and Louie (2002) write, a feeling of loss is
common for children left behind, which can have serious effects for the
childrens’ well-being. Loss usually sets off adaption processes, e.g. grief, which
could be seen in the cases of Cindy and Juliano’s, as well as Rosa’s, sons, who
were emotionally distressed and suffered from health problems due to their
parents’ absences. These children’s experiences clearly show the important
role of emotions for health, and that mind and body are tightly connected, as
mind/body medicine postulates. In the next section, results from the survey
study concerning relations between migration experiences and health status
will be presented, which may further illuminate the effects of separation on
health.
Survey results: migration and self-rated health
It was thus clear from the interviews that the separation within families can
sometimes be very hard, entailing great psychological suffering and
sometimes also having physical health effects. In the study I also investigated
whether relations between migration events and health status could be found
in a larger population, based on the survey data.
The aim of the quantitative analysis on migration and health was
consequently, first, to examine whether there were any associations between
health status (i.e. self-rated physical and mental health166) and socioeconomic situation; and, second and most importantly, to examine whether
associations could be found between health status and individuals with
different migration backgrounds (In-migrants, Left-behinds and Nonmovers)167. It is important to note that, since the study was based on crosssectional data, the analyses mainly provide a picture of the current situations
166 Self-rated health, i.e. questions in which people report how they subjectively perceive their overall health,
is regarded as a reliable and valid tool for measuring health status (see e.g. Emmelin et al. 2006; Eriksson et al.
2010). Regarding self-rated mental health there is strong evidence that it is an accurate measure for mental
morbidity, though more research is needed to validate the tool (see e.g. Mawani & Gilmour 2010).
167 Based on HDSS data on migration events, the sample population was categorized as either “In-migrant”
(person who had moved into the household from another place, no record of out-migration), “Left-behind”
(family member of out-migrant; no personal migration history), or “Non-mover” (person who still lived in
his/her place of birth; no migration history in the family). See Chapter 3 for more information about this
categorization procedure.
255
of different groups, rather than indicating any causal relation between, for
instance, migration background, socio-economic situation and health status.
Furthermore, as very few in the sample population had experiences of inmigration (i.e. those categorized as In-migrants), the analysis of associations
between health status and migration background could only produce sound
results for the groups of Left-behinds and Non-movers, which should be kept
in mind when reading the presentation of results.
The results of the survey study showed that almost three quarters (72%)
reported having “good” physical health (including excellent, very good and
good health), and an even higher share (78%) rated their mental health as
“good” (Table 18)168. Furthermore, there was a significant difference in how
physical health was rated in the two study settings; in León physical health
was rated “good” more often than in Cuatro Santos. Health conditions are
generally poorer in rural areas, largely due to the higher levels of material
deprivation, which is an important determinant of health (e.g. Gatrell & Elliott
2009). There was, however, no statistically significant difference between the
study settings concerning self-rated mental health.
Table 18: Self-rated physical and mental health
All respondents
León
C. Santos
Good physical health
71.8%
80.0% b
68.6% b
Bad physical health
28.2%
20.0% b
31.4% b
Good mental health
77.6%
78.1%
77.5%
Bad mental health
22.4%
21.9%
22.5%
Notes: Based on Questions 8a and 9a, Survey 2008 (see Appendix). “Good” includes the
options “excellent”, “very good” and “good”; and ”bad” includes “bad” and “very bad”. In
weighted percentages. Statistical significance (Pearson Chi-Square): a p<o.001, b p<o.o1.
Binary logistic regression analysis was performed in order to analyse the
socio-economic characteristics and migration experiences of individuals with
good and bad self-rated health. The dependent variables that were used in the
regression analyses were “good self-rated physical health” and “good selfrated mental health”, with values “yes” for those who reported “good” health
(including excellent, very good and good ratings), and “no” for those who
reported “bad” health (including bad and very bad ratings) (based on
questions 8a and 9a, Survey 2008). The independent variables were the same
as described in Chapter 5; besides sex and age (that mostly were used as
168 In the question, the respondent was asked to rate his/her physical and mental health, respectively. The
options were “excellent”, “very good”, “good”, “bad”, and “very bad”. The first three options were grouped into
“good”, and the latter two into “bad”. The vast majority replied either “good” or “bad” (while very few replied
“excellent”, “very good”, and “very bad”). For this reason, binary logistic regression analysis was used.
256
control variables), the most important variables considered socio-economic
status, i.e. poverty (poor/non-poor), education (low-educated/medium-higheducated), and occupation (skilled worker/other), as well as migration
categories, i.e. Non-mover (yes/no), Left-behind (yes/no), and In-migrant
(yes/no) (see Footnote 167). Other important independent variables were
perceived economic and emotional support (yes/no), and variables about
migration/translocal networks (number and location of family members in
other places, as well as immigration status of emigrated relatives)169 (see
Chapter 5, p. 189, for more detailed information about these variables).
Concerning the relationship between health and socio-economic status, the
logistic regression analyses – in contrast to many previous studies reporting a
strong relationship between level of education and health – showed no
significant association between good self-rated physical health and high
education (controlling for the effect of age and sex) (not shown here). The
regressions did, however, show the expected positive association between
being a skilled worker and reporting good health, and the results also showed
a negative association between being poor and having good health; thus it was
less likely that poor persons rated their physical health as good (Table 19).
Table 19: Logistic regression: “Good self-rated physical health”
B
SE
Constant
3.875***
0.371
Woman
-0.296
0.217
-0.057***
0.007
Age
Poor
-0.492*
0.228
Left-behind
-0.483*
1335
0.228
0.230
N (unweighted cases)
Pseudo R square (Nagelkerke)
*** = p<0.001, ** p<0.01, * p< 0.05
This indicates a social gradient in the health status in the case of this study
setting as well. Evidently, younger individuals were also more likely to rate
their physical health as good, which was expected, as health usually
deteriorates with age. Furthermore, concerning the associations between
migration events170 in the household and self-rated health, the results showed
169 More specifically, if the respondent had family members in other places (yes/no) (question 6, Survey 2008);
size of migration network (few/many) (see footnote 133), range of migration network (in Nicaragua/abroad),
location of transnational migrants in the family (USA/other country) (Question 7); and immigration status of
emigrated relatives (“legal”/undocumented) (Question 20).
170 As mentioned at the beginning of the section, the results concerning migration concern Left-behinds (i.e.
family members of out-migrants) and Non-movers (i.e. individuals with no personal experience of migration
and no migration events recorded in the household). The results concerning individuals with personal
migration experiences – the In-migrants (i.e. individuals belonging to households with events of in-migration,
257
a negative association between good physical health and being a so-called
Left-behind (i.e. family member of out-migrants), even when poverty, sex and
age were controlled for (Table 19). Thus, it was less likely that Left-behinds
rated their physical health as good. These findings indicate that those
categorized as Non-movers in our study population (i.e. individuals living in
a household in which no one was living as a migrant in another place) were
more likely to rate their physical health as good, in contrast to the family
members of out-migrants (i.e. Left-behinds). Migration events are thus
associated with self-rated health status, even when age, sex and socioeconomic status (poverty) are controlled for. This association may have
several alternative explanations. For instance, that the left-behinds live in a
stressful situation for different economic, social and emotional reasons. Or,
that health problems in the family may trigger migration, and due to the
healthy migrant selection mechanisms, the healthy individuals are those with
the capacity to leave. Whatever may be the reason, it is obviously more likely
for people in left-behind families to rate their health as bad.
The interviews as well as previous studies have revealed the negative effects of
being an undocumented migrant, and also the stress family members left
behind may experience because of this. When analyzing the association
between having an undocumented relative and good self-rated physical health
a negative association was found in the survey data, also when poverty, age
and sex were controlled for (not shown here). However, the analysis indicates
a strong correlation between socio-economic status and migration status and
it is possible that being a family member to an undocumented migrant is
merely a proxy for being poor. Nonetheless, people who have undocumented
relatives are more likely to rate their health as bad (Table 20).
Table 20: Logistic regression: “Good self-rated physical health”
Constant
Woman
Age
Left-behind
Poor
Undocumented relatives
N (unweighted cases)
Pseudo R square (Nagelkerke)
B
SE
3.888***
0.463
-0.517
0.279
-0.050***
0.008
-0.070
0.289
-0.521
0.293
-0.663*
838
0.225
0.281
*** = p<0.001, ** p<0.01, * p< 0.05
with no registered out-migration events) – were statistically insignificant in the regression analyses, probably
due to the limited number of individuals in this sample group. See Chapter 3 for further details on the sample
groups and the survey design.
258
Logistic regression analyses were also conducted concerning self-rated mental
health (78% rated their mental health as “good”; see Table 18 above). Unlike
the results on self-rated physical health, presented above, the regressions
showed no significant associations between self-rated mental health and
migration, or to socio-economic variables (e.g. poverty) (Table 21). Also, no
statistically significant associations could be found between self-rated mental
health and migration/translocal networks (e.g. where dispersed family
members lived, having undocumented relatives abroad), but we did find a
positive association between those who perceived themselves as having
emotional support and good self-rated mental health (though not with other
indicators of social support or help exchanges, e.g. reception of remittances).
Table 21: Logistic regression: “Good self-rated mental health”
Constant
B
SE
3.058***
0.432
Woman
-0.977***
0.236
Age
-0.045***
0.006
0.698*
0.329
Poor
0.075
0.238
Left-behind
-0.277
1336
0.190
0.245
Emotional support
N (unweighted cases)
Pseudo R square (Nagelkerke)
*** = p<0.001, ** p<0.01, * p< 0.05
Hence, those who perceived themselves as having emotional support were
also more likely to rate their mental health as good. This result is in line with
previous research, which has shown that perceived support is more important
for mental health status than actual support (see e.g. Thoits 1995). The results
also showed that those who rated their mental health as good were more likely
to be younger persons, and men – which was expected, as there are age and
gender differences in mental health as well.
In sum, the findings of the survey study showed that the majority assessed
both their physical and mental health situation as good. Perhaps selfevidently, younger people more often reported being in good condition
healthwise. Non-poor individuals more often reported having good physical
health, which indicates a social gradient in the health status even in the case
of León and Cuatro Santos, Nicaragua. The findings did not indicate a social
gradient in mental health status, but nevertheless that there was a gender
difference, with men more often reporting good mental health. Moreover,
individuals who perceived that they had someone to turn to for emotional
support were also more likely to experience good mental health. The ratings
259
of mental health seemed unaffected by migration events; however, family
members of out-migrants (Left-behinds), especially those with family
members abroad who lacked legal immigration status, more seldom rated
their physical health as good. Thus, individuals who had not moved and who
had no migration history in the family (Non-movers), and those who did not
have undocumented migrants in the family, were more likely to report good
physical health. The survey study thus showed that migration may indeed
affect health, at least self-rated physical health. It also showed that family
members’ undocumentedness may be important for how health is
perceived/rated. Moreover, even in this study setting there are socioeconomic differences in self-rated health in terms of age, gender, occupation
and poverty.
The next part of the chapter will discuss how the study participants handled
the separation caused by migration events. The section begins by discussing
qualitative findings, and thereafter presents results of the survey study
concerning the contact between the respondents and their dispersed family
members.
Parenting and caring at a distance – tensions and coping
strategies
Despite being separated over time and space, transnational families often
maintain a sense of “family-hood” (Bryceson and Vuorela 2002; quoted in
Baldassar & Merla 2013) by employing different strategies (Baldassar & Merla
2013; Schmalzbauer 2008); for example, “negotiating a plan for family or kin
to care for children upon the parent or parents’ departure and until their
return, ensuring that economic remittances are sent to support family wellbeing, and using phone calls, letters and video to stay involved in each other’s
lives” (Schmalzbauer 2008: 334). These practices are part of what has been
called “transnational caregiving” (Baldassar & Merla 2013) and “care at a
distance” (Leifsen & Tymczuk 2012) in the literature. Baldassar and Merla
(2013) emphasize that transnational families are highly sustained by the
exchange of transnational caregiving. The exchanges of care within
transnational families are similar to the forms of care and support generally
exchanged in proximate families (cf. Finch 1989; in Baldassar & Merla 2013);
including, for example, financial, practical and emotional support (e.g.
“hands-on” support, caring about, and the coordination of support provided
by others), given either in a situation of physical co-presence or through
virtual communication (see also Baldassar 2007); and are therefore also
gendered (Carling, Menjívar and Schmalzbauer 2012). Regarding
transnational mothers, Hondagneu-Sotelo and Avila (1997) show that, even
260
though transnational mothers leave their children in the care of others, they
do not regard this as abandoning them. Instead, it leads to rearrangements in
the mother-child interaction, and mothering ties and caregiving are
maintained by regularly sending home money and exchanging letters, photos
and phone calls. Connections and closeness are thus achieved through
communication (see also Sánchez-Carretero 2005; Boccagni 2012).
Transnational caregiving is furthermore, according to Baldassar and Merla
(2013: 7), reciprocal yet uneven: “[t]ransnational caregiving, just like
caregiving in all families (whether separated by migration or not), binds
members together in intergenerational networks of reciprocity and obligation,
love and trust, that are simultaneously fraught with tension, context and
relations of unequal power”. Moreover, transnational care “circulat[es]
among family members over time as well as distance” (ibid.; italics in
original), since care is given and returned at different times and to varying
degrees across the life course. Baldassar and Merla’s work on transnational
care circulation thus extends previous conceptualizations of global care
chains, mentioned earlier, by considering not merely care exchanges between
two people that flow in one direction, but rather “the entire network of
relationships around which care flows” (ibid. p. 9). They thus highlight “how
care circulates around a wide network of friends and family, crisscrossing both
local and national settings” (ibid. p. 12). They furthermore argue that the
exchange of care in transnational families is especially important because
these family constellations usually lack other ways to express family solidarity
and belonging. However, due to the high psychological costs of migration and
family separation, the transnational types of care and the emotional
investments in it, e.g. the sending of remittances, may not necessarily pay off
in terms of better life opportunities for the families involved, or lead to socioeconomic development in the origin (Castañeda & Buck 2011). Caitlin Fouratt
(2014) shows that in the case of Nicaraguan migration to Costa Rica,
migration is a strategy for caring for one’s loved ones, but that it both leads to
improvements and generates instability through absence and separation.
Zentgraf and Chinchilla (2012) similarly argue that both the costs and benefits
of migration, for all the actors involved in the process, must therefore be
recognized when discussing the impacts of transnational family separation.
In the interviews I identified many direct and indirect ways in which the
interviewees handled (i.e. coped with) the translocal lives they were leading,
and expressed their care within translocal social spaces. Next I will present
some of the most important ways of coping, including the efforts of trying to
maintain relations, making plans together, and expressing care by sending
remittances.
261
Trying to maintain relations
In order to maintain relations with distant family members, many
interviewees relied on telephone calls, the Internet (e-mail, video calls), and
visits. For many, the effort to invest in relationships, and maintain good
communication, was an important way to cope with being separated from
their loved ones. In a study on Italian migrants and their left-behind family
members, Baldassar (2008) has similarly shown that her informants put great
effort into creating a “virtual co-presence” by keeping in touch (see also e.g.
Wilding 2006, on the creation of “virtual intimacies”).
Cindy described in the interview how her husband Juliano, who lived and
worked in the US, phoned her every day, even several times a day on
weekends.
Cindy:
“He calls me…daily. We talk every day, but…for example on Fridays, Saturdays
and Sundays, he calls me three times a day. He spends a lot of money on
calling us here.” <<C: Could he speak to your son too in the beginning? He
was little when Juliano left…>> “Yes, the boy could already talk, he talked to
him. That boy is very used to it, he talks a lot, he talks and talks with his
Daddy…”
By communicating this frequently Cindy and Juliano could maintain their
relationship, and Juliano could also stay close to his son. The phone calls were
costly, Cindy said, but the gain of maintaining relations within the family
probably outweighed the economic costs.
Juliano also talked about the importance of having good communication with
Cindy and his son, in order to cope with the separation. He said they
frequently talked over the telephone, and also via Skype (video calls). Juliano
also often talked to his brothers and sisters, who also lived in León, and said
he was very grateful they were still close despite the distance that separated
them.
Both Cindy and Juliano also said that Juliano’s annual visit to Nicaragua was
a way to cope with the separation. Since Juliano made enough money in the
US he could come home for a month every year; usually during Christmas
vacation. At the time of the interview, Juliano was instead home at Easter for
his son’s birthday. He thus had to choose which important family event to be
present for. Both Juliano and Cindy mentioned that they tried to make the
most (aprovechar) of his visits back home, since they missed each other very
much during the rest of the year.
262
Juliano:
“Every time [I] come back, we try to make the most of it [aprovecharlo al
máximo]. …”
Cesar also said in our interview that his main way of keeping in touch with his
family while he was living in Costa Rica was over the phone. He usually called
once a week “to see how the family was doing”, as he said. Cesar also added
that he believed it would be easier to maintain good relations with his family
if he lived closer to home, for instance somewhere near the border (between
Costa Rica and Nicaragua). Then, he would be able to come home for visits
once or twice a month, which he believed would be better: “so I wouldn’t lose
contact with my girls”, as he said. He was therefore planning to go somewhere
closer to Nicaragua on his next trip to Costa Rica.
Maribel also called her children about once a week when she lived in Costa
Rica.
Maribel:
“I called them every weekend, every weekend…because it was an obligation to
do it, so it made me feel better… I called them every weekend, even if it meant
I wouldn’t have enough for food… You know, Costa Rica is very expensive…”
As Maribel said, she nevertheless sometimes had difficulty affording the calls,
since her living expenses were high in Costa Rica. However, since she felt it
was her obligation as a mother to call her children she felt better when she did
it, regardless of the cost, even if it meant going without eating.
The interviews highlighted the importance of keeping in touch in order to
maintain relationships. However, the benefit of this did not come without cost
and sacrifice.
Making plans
Another important way to handle the separation within families was to make
plans in order to have something to look forward to. Many also tried to stay
positive, and to keep the faith. As Cesar said in the interview, he tried to stay
strong and fight in order to reach his goals: “Todo es forzándose, no?” (“One
just has to stay strong, right?”) (see p. 152).
Cindy and Juliano both said they were waiting and hoping for the day the US
residency application for Cindy and their son was approved, so that they could
reunite and live together in Miami. Cindy and Juliano reasoned that when they
all could live there, and if they both worked and no trips to Nicaragua were
263
necessary, they would be able to save money faster in order to realize their
plans to buy a house in León.
Cindy:
“[T]he plan is that when we get there, to stay about three years there, and save
money to buy a house and set up a business here. Well, to save money the two
of us, to buy a house, because… it’s difficult for him… He could…but he would
have to stay there, and not come home for visits, or anything… So at least stay
a couple of years there, to buy a house. So, well, mmm… It’s very difficult to
be there…alone…without seeing your son…”
As seen in the quote, Cindy thought Juliano would be able to save enough
money to buy a house on his own if he stayed in the US for a couple of years
without coming home for visits. However, she did not consider this a good
option, reasoning that it would be too difficult for Juliano to be alone all the
time, without seeing his family, particularly his son. Juliano agreed with Cindy
on this point; as he says in the quote below, they were therefore hoping the
visa would be approved. Besides acquiring a house, Juliano also hoped they
would make enough money to be able to start some sort of business activity in
León that would sustain them.
Juliano:
“What we’re trying to do…maybe this year or the next, she’ll go with the boy
there [to the US]. […] Since I’m a resident, I’ve made an application. Maybe,
if we’re lucky, this year or the next, because everything [the application] is
already approved, thank God. […] My idea is to go there, at last together with
my wife and son, stay there like two-three years, save money for a house,
return… My plan is to save a lot, to try to save a lot of money, and put up
something [a business] that will let us live well, the three of us…”
Juliano and Cindy’s wish and hope for reunification, and the goal they had
established for themselves, as well as taking the necessary steps to make it
come true (i.e. applying for a visa), can be seen as strategies for coping, with
both the difficult economic situation in Nicaragua and the separation from
each other.
Making plans together, in order to have something to look forward to, as well
as staying positive and keeping the faith, were thus important ways the
interviewees coped with the translocal lives they were leading.
Sending dollars shows care171
Many participants in this study sent remittances, both within the borders of
Nicaragua and from abroad (see Chapter 5). For some interviewees, the socio171 Here I paraphrase Deirdre McKay’s (2007) article title “‘Sending Dollars Shows Feeling’ - Emotion and
Economies in Filipino Migration”.
264
economic gains that took place in relation to migration made the separation
from their loved ones slightly easier to cope with. For example, in relation to
the money he was sending to family and friends in Nicaragua, Juliano said it
“felt good” to have the possibility to help others. Maribel and Rosa also made
an effort to see the economic advantages with their migration in order to ease
the separation.
Sending remittances could thus be seen as an act of love, of caring at a
distance. Leifsen and Tymczuk (2012) also understand the act of remitting
money and goods as an important part of what they term “care at a distance”
in their study on the maintenance of transnational social bonds between
Ukrainian and Ecuadorian parents residing in Spain, and their left-behind
children in the origin. McKenzie and Menjívar (2011) furthermore write that
the remittances and gifts that the left-behind Honduran women in their study
received from their emigrated husbands not only contributed to improving
their lives, but also served as reassurances that the men had not forgotten
them, and as expressions of love. Fouratt (2012) similarly shows that the act
of sending remittances for Nicaraguan migrants in Costa Rica is a way of
showing their love, and that they still “remember” the family members back
home.
In sum, the interview study showed a diversity of coping strategies, including
trying to maintain relations, making the most of the time away and together
during visits (aprovechar), making plans together, and expressing care
through providing for the family left behind. Even though care was expressed
and carried out at a distance, the emotional pain of separation was
nevertheless often a constant agony. Maintaining relations with dispersed
family members was thus an important way of coping with separation. The
number who actually did maintain contact with family members in other
countries could be seen in the survey study.
Contact within transnational social spaces
One question in the survey was directed to the respondents who had family
members living abroad, regarding whether they had contact with their
emigrated relatives, and if so, how often and in what ways they kept in touch
(Question 19). About 60% of all respondents had family members living
abroad172, of whom the vast majority (93%) maintained relations with their
dispersed family members. There was a statistically significant difference
between the study settings on this point; in Cuatro Santos, nearly everyone
172 Two-thirds (67%) of those with family members in other places reported that the relatives lived in another
country (see Table 8, p. 133), which means that 60% of all respondents had international migrants in the family.
265
(99.9%) had contact with their emigrated relatives, compared to eight of ten
(79%) in León173. This may be related to the higher number of emigrants to
closely situated countries (Honduras and El Salvador) (see Figure 7, p. 133),
which perhaps facilitates the process of staying in touch, but may also be due
to differences in how the respondents understood and responded to the
question. Regarding the frequency of the contact, it most commonly took place
on a monthly basis (43%), i.e. one to three times per month (Figure 19, next
page). About a fifth (21%) had contact more often, on a weekly basis (1-3 times
per week), and almost the same share (18%) had contact much more seldom,
on a yearly basis (1-3 times per year).
(had contact with emigrated relatives=93 %)
50
43,2
40
30
21,1
17,7
20
10,6
10
0
At least once a
week
At least once a
month
Every other month
Once a year
Figure 19: Contact with emigrated relatives (frequency). Weighted percentages.
Based on Question 17, Survey 2008.
The far most common way to stay in touch with family members abroad was
by telephone (84%) (Table 22). About one of ten (11%) mentioned that contact
was maintained through visits, and about the same share mentioned other
ways (of which the Internet made up 1%)174.
Table 22: Way of contact with emigrated relatives
All respondents
León
Cuatro Santos
Telephone calls
84.0%
92.3%
Visits
10.6%
19.4% c
7.3% c
Other ways*
12.4%
7.9% a,b
14.0%a,b
c
81.0% c
Notes: Based on Question 19, Survey 2008. Weighted percentages. *Other ways includes
options “Internet” and “other way”. a p<o.001, b p<o.o1, c p<o.o5.
There was a significant difference between the study settings in the means of
communication. Almost all those who communicated via the Internet were
173 p>0.001.
174 These results should be seen in light of the access to different means of communication in Nicaragua. While
70% of the Nicaraguan population had access to a telephone in 2010, only 10% had access to the Internet, and
just 4% owned a personal computer (UNDP 2013).
266
León respondents (in León, the Internet made up 5% of the “other ways”,
while in Cuatro Santos only 0.1% mentioned using the Internet of the 14% who
communicated in “other ways”)175. Telephone calls and visits were also more
common in León. In Cuatro Santos, other ways of communication – e.g. letters
and messages (included in “other ways”) – were instead more common176,
perhaps because of the higher number of closely situated relatives, or the
poorer socio-economic living conditions in Cuatro Santos (which most likely
influences the access to telephones and the Internet). Most respondents (87%)
had contact with their emigrated relatives in only one way.
Hence, the findings of the survey study were that most respondents had
contact with their dispersed family members. Nevertheless, 7% of the
respondents with family members abroad did not have contact with them.
Furthermore, quite many respondents (18%) had contact with their family
members only a few times every year. This is important to recognize since the
possibility to stay in contact within transnational families is often an
important way to cope with the separation migration entails, according to the
qualitative findings and previous research. Nevertheless, the regression
analyses presented earlier in this chapter concerning self-rated health, as well
as the analyses on remittances (Chapter 5), showed no significant associations
between these and contact with emigrated relatives; possibly because the
majority in fact had contact, or because no distinctions could be made as to
the importance of this contact (the quality and quantity of communication) in
the analysis, for example, if a person lacked contact with a very close
significant other. As the qualitative findings showed, the lack of contact with
close family members can indeed have great impact on one’s psychological
well-being (for example, child health).
Summary and conclusions
This chapter has scrutinized migration-induced changes in social relations,
particularly family relations; i.e. the translocal geographies of everyday lives
across spaces and places. The chapter highlights the simultaneous
connectedness, the translocal social spaces, and the experiences and
consequences of leading what I call translocal lives. I have shown that the
changes in social relations due to migration events have both direct and
indirect implications on health. Just as the aspects of vulnerability and
suffering were important for the migrants’ experiences and health, they were
likewise important for the effects on social relations (for example,
175 p>0.001.
176 p>0.01.
267
undocumented migrants had fewer possibilities to visit their family in
Nicaragua, and were in a more vulnerable situation which made their family
members worry more for their sake).
One important result from the interview study was how emotionally affected
the interviewees were by migration events, and the resulting translocal lives
they were leading. The findings are in line with previous research discussing
the effects of migration on emotional well-being (see e.g. Silver). Not only
positive and negative but also ambivalent emotions were expressed in the
interviews when they talked about their lives (as influenced by migration).
Most interviewees expressed that the separation was hard on them, although
some welcomed it because of destructive family relations that were brought to
an end thanks to migration events. The interviewees who had difficulties
connected to the separation within the family (the translocal lives) expressed
experiences of mental suffering; migration thus entailed psychological costs
for many. These findings confirm previous studies showing that migration
may increase feelings of loneliness, longing and depressive symptoms, for
example (ibid; Baldassar 2008; Schmalzbauer 2004). Several interviewees
also mentioned that the family relations had changed due to migration,
particularly the parent-child relations, sometimes with negative consequences
on child health. Moreover, some migrating mothers experienced great
difficulty being separated from their children, which should be seen in light of
the fact that Nicaraguan mothers, due to gender ideologies, are expected to
take care of their children to a greater extent than men. Previous research also
shows how particularly transnational mothers feel stress at leaving their
children behind, partly because they are still responsible for the emotional
care of children (e.g. Parreñas 2005; Hondagneu-Sotelo & Avila 1997). The indepth interviews also showed that spousal relations were effected, sometimes
causing worry over the other spouse’s health or fear of unfaithfulness and
abandonment.
It was thus clear from the interviews that the separation within families was
often very hard, entailing great psychological suffering and sometimes also
physical health effects. Still, some interviewees also highlighted positive
aspects of separation (freedom from abuse, for example), which Silver (2011)
also shows. For some, migration produced mixed, or ambivalent, emotions.
Both gains and losses were experienced with migration, primarily economic
advantages and psychological costs. Sometimes the advantages did not ease
the pain of separation. Many contradictory feelings were thus experienced by
the interviewees, similarly to what Svaŝek (2008) shows. All these findings are
important in relation to research highlighting the role of emotions in stress,
health and coping.
268
The findings of the survey study were that the majority assessed both their
physical and mental health situation as good. Perhaps self-evidently, younger
people more often reported being in good health, both physically and
mentally. Poor individuals more often reported having bad physical health.
This indicates a social gradient in the health status in the case of León and
Cuatro Santos, Nicaragua as well. The survey did not show a social gradient in
mental health status, but nevertheless that there was a gender difference, with
men more often reporting good mental health. Moreover, individuals who
perceived that they had someone to turn to for emotional support were also
more likely to experience good mental health. The ratings of mental health
seemed unaffected by migration events; however, those who were left-behinds
(i.e. family members of out-migrants), especially those who had family
members abroad who lacked legal immigration status, more often rated their
physical health as bad. The survey study thus showed that migration may
indeed affect health, at least self-rated physical health. It also showed that
family members’ undocumentedness may be important for how health is
perceived and rated. Moreover, in this study setting there are also socioeconomic differences in self-rated health in terms of age, gender, occupation
and poverty.
Strategies of coping with translocal lives were also highlighted in the chapter,
i.e. ways of maintaining relations and family-hood translocally. The
qualitative study exposed many direct and indirect ways in which the
interviewees handled the translocal lives they were leading. Some of the most
important ways of coping were trying to maintain relations (through
telephone calls and visits), making the most of the time away and together
during visits (aprovechar), making plans together, and expressing care by
providing for the family and sending remittances. These ways of coping with
separation have been seen in previous studies as ways of caring at a distance
(e.g. Leifsen & Tymczuk 2012; Fouratt 2014). Even though care was expressed
and carried out at a distance, the emotional pain of separation was
nevertheless often a constant agony. Maintaining relations with dispersed
family members was thus an important way of coping with separation. The
survey study also showed that contact between migrants and left-behinds, i.e.
contact within transnational social spaces, was a wide-ranging phenomenon.
The majority indeed kept in touch with their dispersed family members
(mainly through telephone calls and visits). Nevertheless, the findings also
showed that 7% of the respondents with family members abroad did not have
contact with them, and that many only had contact with their family members
a few times a year. This is important, for as the interviews showed, having the
possibility to stay in contact within transnational (translocal) families is often
an important way of coping with the separation migration entails.
269
270
PART III:
CLOSING OF THE THESIS
Photo: Mariela Contreras
271
272
CHAPTER EIGHT
Concluding discussion
Tracing health within the migration process
This thesis has investigated relations between migration and health – what I
call the migration-health nexus – in Nicaragua. I have examined both how
migration affects health and how health affects migration, and how different
experiences of migration relate to health during different stages of the
migration process and for the different actors involved, i.e. both migrants and
family members of migrants (left-behinds). Health concerns have been traced
within the migration process, in the different phases and places involved in
the process; i.e. in places of origin, during travel, at the destination and after
return.
Migration, health and social transformations in Nicaragua
Migration-health relations in Nicaragua are connected to broader economic,
social and political factors and to the country’s historical experiences of
colonization, neo-colonization and structural adjustments. Profound socioeconomic transformations have taken place, and the country’s migration
patterns and health trends have also changed in relation to this. I provided a
thick description of the study context (Chapter 4) in order to place the
migration-health nexus in its context. In my attempt to “historicise the
present” I could see resemblances and links between contemporary migration
patterns and the historical movements caused by natural disasters, military
conflicts and regional economic dependencies. I identified certain phases in
the mobility patterns and a general trend where migration has gone from
being mostly an internal and regional matter to an increasingly international
process also characterized by a feminization of migration. The motivations for
migration have been influenced by a mix of economic, political and sociocultural factors; yet in recent times economic ones have predominated.
Transnational relations and the number of divided families have increased,
and as a result also the amount of remittances received in the country.
Remittances are now an important source of income for a large part of the
population, and often invested in health care and education.
273
Complex migration-health relations – the importance of
contextualization and social differences
The in-depth interviews showed the complexity and multidimensional nature
of migration-health relations over the life course. Both gains and losses, i.e.
positive and negative consequences, as well as direct and indirect effects, were
experienced with migration, and health could also directly and indirectly
influence migration. Moreover, the interviews showed that migrant categories
were overlapping, i.e. that one and the same person could have several
different experiences of migration (both of personal migration and of being
left behind by migrating family members). This was also noticed in the work
to construct the sample for the survey study, which made a strict
categorization necessary, i.e. that persons with several experiences were
excluded from the study population (see Chapter 3). A conclusion of this study
is that the overlapping of migrant categories has to be acknowledged in
investigations of migration and health, since it may cause confounding effects.
In the interviews I identified three main themes that embraced different
aspects of migration-health relations – mobile livelihoods, migrant health
and translocal lives. These themes were paid attention to in one empirical
chapter each. I also identified three key aspects through the interview analysis
– vulnerability, suffering and coping – which were crucial for the experiences
and effects of migration. The degree of vulnerability and suffering varied for
different persons, and coping was more or less openly expressed in the
interviews. Based on this I argue that contextualization and acknowledgement
of social differences are crucial for the enactment of the migration-health
nexus.
The embeddedness of health in mobile livelihoods
The qualitative and quantitative material showed how migration was a
common phenomenon in the study setting, and that migrant networks were
salient features, although they varied in extent and character. The findings
from the survey study confirmed previous reports on Nicaraguan migration
patterns. In relation to the research on migration dynamics, it is clear that the
patterns of Nicaraguan migrations have unfolded transnational dynamics that
can contribute to further international migration. The in-depth interviews
showed how migration networks could play a crucial role in the decisions to
migrate. The qualitative data here thus contributed with a deeper
understanding of the quantitative findings on migration networks.
A central finding from the qualitative study was that contemporary
Nicaraguan migrations are primarily related to the strategies of making a
274
living and the struggle for a better life. Migration is an important livelihood
strategy in the study setting due to poverty, unemployment, low incomes,
difficulties to make ends meet, and vulnerable livelihoods. When
opportunities are scarce (locally or nationally) many migrate in order to find
better prospects in other places; migration is thus used as a way to cope with
hardships. I use the concept of mobile livelihoods (Olwig & Sørensen 2002) to
characterize this process as it highlights the embeddedness of migration in
people’s livelihoods and captures many of the features encountered in the
study context. A translocal type of mobile livelihoods was practiced, involving
both different places in Nicaragua and abroad. Even though economic motives
for migration were emphasized (both in the interviews and the survey), many
other reasons were salient in the empirical material, e.g. social aspects,
education, and health. The complexity of decision-making processes was
obvious in the in-depth interviews, and these also provided a contextualized
understanding of the stated motives behind the intentions to move as
expressed in the survey study. The decision to move or to stay, and where to
go, is based on a variety of considerations. Migrants’ decision-making does
not take place once-and-for-all and in isolation, the underlying causes of
migration must be sought for in historical socio-structural processes, as I
argue in Chapter 4. The biographical approach was useful for analysing these
complexities, as it allowed the processual and relational nature of migration –
and the ways the migration-health nexus was enacted over time and space –
to be understood as part of the person’s migration biography.
Interestingly, in the survey study health was seldomly stated to be the reason
for the intentions to move to other places; however, the qualitative in-depth
interviews showed that health issues often were either embedded in other
motives (e.g. economic) or an important reason in its own right. According to
the qualitative findings, health issues were thus both indirectly embedded in
people’s mobile livelihoods and in the struggle for a better life, as well as
directly influencing decisions to move or to stay. The interviewees mentioned
both personal health problems and health concerns of family members as
motivating migration/non-migration acts, e.g. death or injury due to natural
disasters, illness, emotional stress (longing, worry, suffering), fear of crime
and violence, sexual abuse, and reproductive health. Hence, people’s health
and their access and use of health services are unquestionably issues of
concern in Nicaraguan migration processes. Health concerns make the
dilemmas surrounding hardships and migration extra critical.
The qualitative findings poignantly showed how the widespread violence and
abuse of Nicaraguan women influenced the migration decision processes, and
that Nicaraguan gender ideologies and parenting practices shaped migration
decisions and the experiences of migration. The mothers’ narratives on work
275
and the struggle for a better life in this study confirm earlier research which
shows how Nicaraguan mothers are expected to be self-sacrificing, hardworking, caring, and always fighting for the survival and upbringing of their
children, and thus responsible for the household’s social reproduction to a
high degree. Even though a shared mothering is commonly practiced,
Nicaraguan migrant mothers maintain the responsibility for the household
during their absence. This study shows, in line with other research, that when
women migrate they develop mothering practices from afar, while enduring
the continued pressures and difficulties caused by the separation from the
children.
The importance of social networks and translocal social support
for health
Due to widespread economic distress in Nicaragua people depend on others
to survive, through mutual giving and taking within social networks. In the
absence of institutional support family support networks are central resources
in the process of social reproduction of individuals and their families, by
allowing access to resources (education, work, income, health) and by carrying
out daily activities, such as care of children and for the sick. Helping each other
is thus a way of coping with hardships. Nicaraguan family networks rely
heavily on women, of older and younger generations. The emergence of
translocal geographies (Brickell & Datta 2011) change the demands on family
support networks, for instance the type of help that is needed. In my data I
found a varitey of ways in which help was provided through migrants’ social
networks. The findings from both the qualitative and quantitative studies were
that both local and transnational (hence, translocal) social networks provided
help, and eased people’s vulnerability. For the interviewees, the help provided
by friends and family, as well as by organizations (e.g. development aid), was
often important for getting by (surviving). About a fifth of the survey
respondents said that they received and provided help (economic or
emotional). However, a third of the survey respondents did not feel that they
had someone to turn to for material support, which makes this group
particularly vulnerable. For some interviewees, the lack of a supporting social
network in Nicaragua was a motivational force to migrate. These findings are
important since previous research has shown that social support (i.e. people’s
social ties and social integration) is important for health and for coping with
stress.
The most common type of help among the study population was remittances,
and I argue that remittances can be seen as a kind of instrumental social
support. The survey study showed, similarly to other reports, that almost a
fifth of the respondents received money remittances. Those who had relatives
276
in the US more often received remittances. Moreover, those who were skilled
workers did not receive remittances as often as persons with other
occupations. There was thus a social differentiation in remittance patterns
(i.e. those with a somewhat better socieo-economic position did not receive
remittances as often). The majority of the remittances came from abroad, but
14% ware sent from within the the country. Moreover, even though the
majority used the remittances for daily consumption, almost a quarter used
these resources for health purposes, and 13% for education. These are
important findings that show that both closer and more distant support can
enhance people’s access to health care and medicine, as well as indirectly
influence health through improving people’s material conditions (e.g. food,
housing) and education. The in-depth interviews showed a varied picture of
how important remittances were for the household economy, but sometimes
the money sent from abroad or from other places within Nicaragua could be
crucial in times of health crises in order to receive necessary treatment. The
survey study also showed that remittances were important during periods of
illness; either in the form of medicine, or in the form of money that was used
to buy medicine or private health care. These findings point to what other
studies previously have shown, i.e. that the access to health care and medicine
in Nicaragua is socially differentiated, and thus related to people’s economic
resources. The survey study also showed that only 12% of the respondents had
access to social insurance, which makes remittances a vital resource since
those who lack social insurance often have a limited access to health care in
Nicaragua. The remittances that were sent during periods of illness mostly
came from other places within Nicaragua, which shows that local social
networks were more important in this case than transnational networks.
Under these circumstances, with high levels of poverty, difficulties making a
living, little access to social insurance, and an exclusionary social regime, the
resources from migration (i.e. remittances) have become a way to compensate
for the lacking public sector in Nicaragua. In the words of Caitlin Fouratt
(2014: 77), remittances “allow families to bypass overworked and
underfunded public services and to buy health, education, and hope for the
future in the private sector”. Some argue that when families use remittances
to access services in the private sector they take part in the “privatization of
public services” (Hernandez & Coutin 2006; in Fouratt 2014), by playing into
the neo-liberal state’s hands and thereby freeing the state from its obligations
towards its citizens. When remittance sending is emphasized as a moral act or
an act of love, as is done in many migrant sending countries, it thus “obscures
how the state, in relying on capitalizing on remittances despite the conditions
under which they are generated, reinforce the insecurity and uncertainty of
migrants and their families left behind” (Fouratt 2014: 78). The Nicaraguan
people’s right to health – as stipulated by law – is certainly not met under
277
these conditions; hence, the population is not guaranteed their social rights of
citizenship.
Regarding the development potentials of remittances, I argue that remittances
can lead to improvements for those who receive them. The study has shown
that remittances are an important part of many families’ livelihoods. Even
though some regard the investments in food, clothes, housing, education, and
health care as “unproductive”, and therefore unable to function as incitaments
for development, they are important for sustaining development, and the
persons involved can experience obvious and immideate effects as a result of
the money that is received. Thus, in the words of Jennings and Clarke (2005:
688-9), “[f]eeding, clothing, and educating 20 per cent of Nicaragua's
population must be regarded as a positive development outcome for the
country”, as it can produce significant nutritional and health advantages.
However, remittances do not reach all Nicaraguans equally, especially not the
poorest. Even though there is evidence that children’s enrolment rates in
school and health (e.g. anthropometric measures and vaccination rates) have
been improved in households receiving remittances, and that children more
often are delivered by a doctor in remittance-receiving households, the
question is raised whether remittances can contribute to development in
Nicaragua since poverty levels seem unaffected by remittances. I have shown
in this study that even though people may have the intention to use
remittances for “productive” investments (e.g. business) that could improve
living conditions in the long run, the socio-structural context (e.g. poverty and
the non-inclusive health care system) is in the way for change, because the
remittances must be used for more pressing concerns because of the lacking
public sector. Lastly, there are many negative aspects of migration that need
to be taken into account when discussing the development effects of migration
and remittances, for example family separation, and risks, exploitation and
“othering” during the migration experience. In order for the development
effects to reach the whole population in Nicaragua greater socio-economic
reforms need to take place, not least in the health sector.
The stresses of migration – migrants’ vulnerability and suffering
Both the international and internal migrants that were interviewed in this
study experienced the effects of being a “stranger” in a new place due to the
dislocations and disruptions that take place at migration. The most important
effects of the changes in environment for the interviewees were feelings of loss
(e.g. homesickness, longing), bodily effects due to environmental changes,
and the stress of “othering”. Previous research has shown how stressful it can
be to leave familiar settings and family members behind, and to adapt to a new
place and culture. For example, “othering” (i.e. xenophobia) and racism (i.e.
278
discrimination of certain groups) can produce great stress and other negative
health consequences for migrants, which points to the acuteness of the
situation for those with such experiences. Some interviewees in this study
nevertheless experienced improvements in their social milieu, which is also
important to acknowledge. And, some did not experience “othering” because
of their “whiteness”; hence, skin colour influenced the exposure to “othering”.
An important finding from the qualitative study was that social differences
were of utmost importance for how migration acts were experienced by the
migrants and for the consequences they had on health. In relation to border
crossings, the undocumented migrants were particularly vulnerable and
exposed to high risks. Borders are often dangerous settings, and this study has
shown how migrants suffer both physically and mentally during the journey.
The literature points to a relation between increased border security and
migrant fatalities, partly due to a redistribution of migratory flows into more
remote and dangerous areas. As Heyman (2014: 123-4) argues, “border
enforcement in general, and especially the escalation since 1993, produces
illegality effects that endure across time and space”; effects such as
psychological scars, physical or direct violence (e.g. deaths and armed
robbery), and structural violence (e.g. anxiety, subordination and
exploitation). The increasing number of deaths at the Mexican-US border
show the devastating effects of border politics. The issues of borders and
border politics are thus highly relevant in studies of international migration;
also in this study that includes both documented and undocumented
international migrants, as well as family members to such, who all witnessed
the implications borders and cross-border movements in their lives and for
their health.
While abroad, lacking proper documentation also influenced migrants’ health
and access to health care. The interviewees talked about how they, or other
undocumented migrants, suffered from stress because of the fear of getting
caught by the police, and that the access to health care often was limited.
Moreover, the undocumented migrants were often in a more precarious work
situation, in which employers took advantage of their weak social position, by
giving them less pay, less protection, and less insurance. Other migrant
workers (besides the undocumented) were also immersed in the context of
precarious labour relations, since today’s global, capitalist labour system is
hierarchically organized, geographically differentiated, racialized and
gendered, as well as characterized by a high degree of precariousness, and
exploits workers based on their social position. There is research that points
to the negative health effects of this precariousness. Some internal migrants
in this study did however experience an improved situation, both workwise
279
and in terms of the access to health care, which is important to take account
of.
The in-depth interviews also highlighted that the process of return can be
experienced as stressful. Return migrants’ health is determined by a
cumulative exposure to risks and behaviours during the entire migration
process. The interviewees in this study experienced the process of returning
home after migration as more or less smooth, and more or less positive, for
example depending on what had motivated migration, the surrounding
circumstances, the experiences during migration (e.g risks, traumas), and
whether migration was experienced as “successful” or not.
The health effects of separation and coping strategies
Since mobile livelihoods most often take place within the realms of
households, they consequently often entail separation between family
members. Research shows that separation from family may induce great
stress, and affect the emotional well-being, and sometimes even cause
depression, for both migrants and their family members that remain in their
countries of origin. This study shows that the changes in social relations due
to migration events cause both direct and indirect implications for health.
Emotions were highly in play for the interviewees that experienced separation,
which confirms the findings of many previous studies. Even though some
interviewees expressed positive feelings of relief and empowerment, or
ambivalent feelings (e.g. joy for economic gains, but sadness due to
separation), most interviewees said that separation was hard and painful, thus
entailing high psychological costs. Anxiety and worry were commonly
expressed by the interviewees.
Similarly to previous research, the survey study showed that there was a social
gradient in the health status in the study settings (i.e. poor individuals less
often rated their physical health status as good). Interestingly, those who were
left-behinds (i.e. family members to out-migrants), and especially those who
had family members abroad who lacked legal immigration status, more often
rated their physical health as bad. The findings of the survey study were thus
that migration can indeed affect health, at least self-rated physical health.
And, that family members’ undocumentedness can be important for how
health is perceived and rated. Similarly to previous studies, perceived
emotional support was in this study important for how mental health was
rated (i.e. those who perceived that they had someone to turn to for emotional
support more often rated their mental health status as good), however mental
health seemed unaffected by migration events. This contradicts the qualitative
280
findings, which showed that left-behinds often experience emotional distress,
and points to the advantage with the use of a mixed-methods approach.
The family undergoes fundamental transformations in relation to
transnational migration, and these changes may cause stress for both the
migrants and the family members left behind. The in-depth interviews showed
that the relationship of spouses could be difficult to maintain, that migration
could led to abandonment and dissolution of the family, that transnational
mothers were in a particularly stressful situation because they were
responsible both for providing materially and for taking emotional care of
their left behind children (confirming previous research on transnational
motherhood), and that the absence of parents caused negative changes for
parent-child relations and affected child health negatively.
The study further showed, similarly to previous studies, that different
strategies were employed to maintain relations within the divided families, i.e.
to cope with separation. The most important ways of coping, of transnational
caregiving (Baldassar & Merla 2013), were trying to maintain relations
through communication and visits, making the most of the time away and
together during visits (aprovechar), making plans together, trying to stay
positive and to keep faith, and expressing care through sending remittances.
The survey study showed that the majority kept in touch with emigrated
family members, which is positive since contact could be very important to
cope with separation according to the qualitative study. However, 7% did not
have any contact at all, and about a fifth only had contact a few times a year,
which is important to highlight since it may be experienced as difficult.
Advantages and disadvantages
The findings of this study highlight that migration and health can be related
in both positive and negative ways. Through migration, women can see an end
to physical violence and sexual abuse. Internal migrants can improve their
access to health care and medicine. Vulnerabilities related to the
unpredictable nature conditions can be avoided through moving. And,
through the money made from migrant work people’s everyday lives and
health can be improved, in terms of better nutrition, housing, and access to
education, health care and medicine. Health can nevertheless also be
negatively affected by migration. Both internal and international migrants can
experience stress while moving to a new place. International migrants can
have difficulties accessing health care in the destination. They can also
experience the stress of “othering” and face xenophobic attitudes and be
discriminated against. Migrants are often vulnerable, since they are living in
new surroundings, perhaps lacking social contacts, and often enduring
281
inadequate housing conditions as well as precarious and dangerous work
situations. The bodies of migrants are connected to larger relations of
inequality and power, which have effects on both the mental and physical
health of migrants. The vulnerability, stress experiences and sufferings of
migrants vary, however; the undocumented migrants face a particularly
stressful situation both during transit and in the destination, which also can
influence health at return. Social differences in terms of (un)documentedness
– as well as skin colour – are decisive in how the migration experience takes
shape. Furthermore, many who are separated from their families due to
migration experience mental suffering. Family members left behind do not
rate their physical health as good as often as those who do not experience
separation due to migration.
Migration thus involves both advantages and disadvantages for health, and
health can influence migration in a number of ways. The findings from the
study clearly show that personal characteristics – that is, who a person is in
terms of gender, class, ethnicity, and legal immigration status – matter for the
enactment of the migration-health nexus. In all, an interplay of individual,
social and structural factors influence the outcome.
*
*
*
*
*
*
*
I started this thesis with presenting the stories of two Latin American migrants
– Carmen from Bolivia and José Luis from Honduras. Their accounts
highlight that the experiences of the interviewees and survey respondents in
this thesis are not unique for Nicaraguans but relevant also in other contexts
with similar characteristics. In agreement with Jennings and Clarke (2005) I
conclude that the decisions to migrate under the circumstances of global
inequalities, precarious work relations, and non-inclusive health care systems
often involve a choice between two bad options – to remain poor,
marginalized and with little resources to attend to health care needs, or run
the risk of migration and endure the emotional pain of separation from loved
ones in order to have a better life in the future. The situation for the
individuals involved in this process is crucial to acknowledge. Even though
some experience positive effects, this thesis clearly shows that migration has
many negative impacts for the health of both migrants and family members
left behind. Migrants’ and migrant families’ social and health rights are thus
issues of major concern. The need for a medical citizenship that would ensure
all human’s right to health regardless of national citizenship or residence is
more pressing than ever, and is a matter of social justice that only can find
global solutions.
282
Resumen en español
En esta tesis se ha investigado la relación entre la migración y la salud en el
caso de Nicaragua – lo que he llamado el nexo entre migración y salud. La
migración y la salud son procesos sociales y geográficos que se influyen entre
sí de una manera bidireccional (Gatrell y Elliott 2009; Smith & Easterlow
2005; Jatrana, Graham y Boyle 2005); consecuentemente, esta tesis ha
estudiado tanto cómo la migración afecta a la salud y cómo la salud afecta la
migración de las personas. Asimismo, se ha indagado cómo los diferentes
tipos de migraciones se relacionan con la salud durante las diferentes etapas
del proceso migratorio de los actores involucrados (los migrantes y los
miembros sus familias – “los que se han quedado atrás”). Por lo tanto, se ha
hecho un rastreo de la salud de los actores involucrados en las diferentes fases
y sitios geográficos del proceso migratorio (las condiciones en el lugar de
origen, durante el tránsito, en el lugar de destino, y al regresar) (ver los marcos
conceptuales desarrollados por Haour-Knipe 2013, y Zimmerman, Kiss &
Hossain 2011). En esta tesis, la salud es entendida de manera integral usando
un enfoque biopsicosocial y de “mente/cuerpo” (véase White 2005, y Dreher,
2004); esto implica tener un enfoque crítico que reconoce la influencia de
factores económicos, políticos, culturales, sociales, y relaciones de poder que
producen desigualdades/inequidades en la salud de las personas (por
ejemplo, Rosenberg y Wilson 2005; Moon 2009). Por otra parte, basada en la
perspectiva relacional entre lugar y espacio, yo hago hincapié en la
importancia que el contexto local, las relaciones entre los individuos, y los
contextos más amplios tienen para la comprensión de la salud (Parr y Butler
1999).
El material empírico que se utilizó para esta tesis incluye entrevistas
cualitativas y encuestas que se recolectaron entre los años 2006-2008 (con
una visita de seguimiento en el 2013) en León y Cuatro Santos, Nicaragua. Las
entrevistas cualitativas fueron biográficas (Halfacree y Boyle, 1993), y tenían
como fin que las historias sobre migración y salud fueran desarrolladas dentro
de las biografías migratorias de los/as entrevistados (5 hombres y 10 mujeres,
con diferentes orígenes). Las entrevistas se analizaron mediante el enfoque
biográfico y la teoría fundamentada constructivista (Charmaz 2003). El
estudio tipo encuesta se realizó en dos etapas (2007, 2008) dentro de los
sistemas de vigilancia en salud y demografía (HDSS) en León y Cuatro Santos
(véase Peña et al 2008; Pérez 2012). Los encuestados (n=1383) eran personas
con diferentes experiencias de migración (clasificados como “no-migrantes”,
“dejados atrás”, o “inmigrantes”), y con diferente estados de salud
(“saludable”, “enfermo crónico”, y “otras enfermedades”). Los datos
283
cuantitativos fueron analizados utilizando estadísticas descriptivas y
regresión logística binaria.
Migración, la salud y las transformaciones sociales en Nicaragua
La relación entre la migración y salud en Nicaragua está vinculada a factores
económicos, sociales, políticos, experiencias históricas de colonización, neocolonización y ajustes estructurales del país que han contribuido a profundas
transformaciones socio-económicas. En esta tesis se ha tratado de examinar
cómo la salud se relaciona con la migración en este contexto en particular; y
pude ver similitudes y vínculos entre los patrones migratorios
contemporáneos e históricos. La tendencia general es que la migración ha
pasado de ser principalmente un asunto interno y regional, a un proceso cada
vez más internacional. Históricamente, los incentivos para la migración han
sido influenciados por una mezcla de factores económicos, políticos y socioculturales, pero en los últimos tiempos los factores económicos han
aumentado en importancia (por ejemplo, Morales y Castro 2002). Asimismo,
en los últimos años se ha producido una “feminización” de la migración (IOM
2013). Como consecuencia, las relaciones transnacionales, el número de
familias divididas y la cantidad de remesas recibidas en el país también se han
incrementado dramáticamente. Las remesas se han constituido en una
importante fuente de ingresos para una gran parte de la población, y muy a
menudo son invertidas en el cuidado de la salud y la educación en un contexto
donde el sector público se ha visto reducido.
Este estudio muestra que la migración era común en el área del estudio. A
pesar de que no todos los encuestados tenían experiencias personales de
migración, las redes de migrantes fueron una de las características más
destacadas aunque estas variaban en extensión y carácter. Los resultados del
estudio confirmaron los informes de encuestas anteriores sobre los patrones
de migración en Nicaragua (por ejemplo, la OIM 2013; PNUD 2009). En
relación a la investigación sobre la dinámica de la migración (Faist 2000;
Glick Schiller y Faist 2010; Portes, Guarnizo y Landolt 1999; Tollefsen
Altamirano 2000), es claro que en los patrones de las migraciones
nicaragüenses han desarrollado dinámicas transnacionales que pueden
contribuir a una mayor migración internacional.
Complejas relaciones de migración y salud, la importancia de la
contextualización y reconocimiento de las diferencias sociales
Las entrevistas a profundidad mostraron claramente la complejidad y el
carácter multidimensional de la relación entre la migración y la salud durante
284
el transcurso de la vida. Las experiencias migratorias generaron ganancias y
pérdidas (consecuencias positivas y negativas), así como efectos directos e
indirectos en la vida de las personas. Asimismo, se evidenció que la salud
también podría influir directa e indirectamente en la migración. Las
entrevistas también mostraron que las categorías de migrantes a menudo se
intercalan, es decir, que una misma persona puede tener diferentes
experiencias de migración (tanto de la migración personal y de ser “dejado
atrás” por la migración de miembros de la familia). Esto también se observó
durante la construcción de la muestra para el estudio tipo encuesta que hizo
necesaria una clasificación estricta de las personas; por ejemplo, este hecho
hizo que las personas con diversas experiencias migratorias fueran excluidas
de la población de estudio. Una conclusión de este estudio es que este traslape
de las categorías migratorias debe de ser reconocido en futuras
investigaciones sobre migración y salud, ya que podría causar efectos de
confusión en al análisis de la información.
Yo identifiqué tres temas principales en las entrevistas cualitativas que
abarcan diferentes aspectos de la relación entre la migración y la salud:
sustentos móviles, salud de los migrantes y vidas translocales. También
identifiqué tres aspectos claves – vulnerabilidad, sufrimiento y
afrontamiento – que fueron cruciales en las experiencias y los efectos de la
migración. El grado de vulnerabilidad y sufrimiento variaron para diferentes
personas, y el afrontamiento fue más o menos expresado abiertamente en las
entrevistas. Tomando como base esto, sostengo que la contextualización y el
reconocimiento de las diferencias sociales son cruciales para la descripción de
la relación entre migración y salud.
El arraigo de la salud en los sustentos móviles
Como lo han mostrado investigaciones previas sobre las motivaciones para la
migración, la decisión de trasladarse o quedarse, y de dónde ir, se basa en una
variedad de consideraciones acerca de la situación de vida actual en el lugar
de residencia, y de las expectativas acerca de posibles resultados futuros en
destinos alternativos (de Jong y Gardner, 1981; Robinson 1996; Skeldon
1990). Por otra parte, la decisión de migrar no se produce de una vez o de
manera aislada (Halfacree y Boyle, 1993). Las causas subyacentes de la
migración también deben buscarse en los procesos históricos y socioestructurales.
Mi interpretación de las migraciones contemporáneas nicaragüenses es que
estas están principalmente relacionadas con las estrategias para ganarse la
vida y la lucha por una vida mejor (seguir adelante). La migración es una
285
estrategia de subsistencia importante en el contexto nicaragüense debido a la
pobreza, el desempleo, los bajos ingresos, y los trabajos vulnerables. Por lo
tanto, cuando las oportunidades son escasas (a nivel local o nacional) muchos
migran con el fin de encontrar mejores perspectivas en otros lugares. Se utilizó
el concepto de “sustentos móviles” (Olwig y Sørensen 2002) para caracterizar
este proceso, ya que destaca el arraigo de la migración en la forma de vida de
las personas y capta muchas de las características encontradas en el contexto
de estudio. Un tipo “translocal” de las formas de sustentos móviles se
practicaba, involucrando la movilidad tanto a diferentes lugares en Nicaragua
como en el extranjero.
A pesar de que se hizo hincapié en los motivos económicos para la migración
(tanto en las entrevistas y la encuesta), muchas otras razones sobresalieron en
el material empírico; por ejemplo, aspectos sociales, educativos y de salud. En
las entrevistas a profundidad se observó la complejidad en el proceso de la
toma de decisiones, lo que también proporciona una comprensión más
contextualizada de los motivos que hay detrás de las intenciones de migrar
(como se expresa en los datos del estudio de encuesta). Las redes de migración
a veces juegan un papel crucial en las decisiones para migrar. Curiosamente,
en la encuesta, la salud rara vez fue señalada como una razón en las
intenciones de mudarse a otros lugares; sin embargo, las entrevistas a
profundidad mostraron que los problemas de salud a menudo se incluyeron
ya sea en otros motivos (por ejemplo, económico), o una razón importante por
decisión propia. De acuerdo con los resultados cualitativos, los problemas de
salud influían indirectamente en los sustentos móviles de las personas y en la
lucha por una vida mejor, además de influir directamente en la decisión de
moverse o de quedarse. Los entrevistados mencionaron ambos problemas;
problemas de salud personales y problemas de salud de los miembros de la
familia como la motivación de los actos de migración/no migración. Por
ejemplo, los desastres naturales, las enfermedades, el estrés emocional (deseo,
preocupación, sufrimiento), el temor a la delincuencia y la violencia, el abuso
sexual y la salud reproductiva fueron mencionadas como causas importantes
del proceso migratorio. La salud de las personas, su acceso y uso de los
servicios de salud son sin duda temas de interés en los procesos de migración
en Nicaragua. Las entrevistas mostraron conmovedoramente cómo la
violencia generalizada y el abuso hacia las mujeres nicaragüenses también
influyen en el proceso de toma de decisión de migrar. Claramente, las
ideologías de género en Nicaragua y los modelos de crianza de los padres
influían activamente en la decisión de migrar y en las experiencias de la
migración.
286
La importancia de las redes sociales y el apoyo social translocal
para la salud
Debido a la crisis económica generalizada en Nicaragua las personas
dependen de otros para sobrevivir, especialmente a través del apoyo mutuo
dentro de las redes sociales (Johansson 1999; Mulinari 1995; Lancaster 1992;
Aragão-Lagergren 1997). Ante la falta de apoyo institucional, las redes de
apoyo familiar son los recursos centrales en el proceso de reproducción social
de los individuos y sus familias, al permitir el acceso a los recursos (educación,
trabajo, ingresos, salud), y mediante la realización de las actividades diarias,
tales como el cuidado de los niños y de los enfermos (Martínez Franzoni y
Voorend 2011). La aparición de “geografías translocales” (Brickell y Datta
2011) cambia las demandas de las redes de apoyo de la familia, por ejemplo,
el tipo de ayuda que se necesita.
En mis datos me encontré con una variedad de formas en las que se
proporcionó ayuda a través de las redes sociales de los migrantes. Las
entrevistas a profundidad y las encuestas mostraron que tanto las redes
sociales locales como las transnacionales proveyeron ayuda, y por lo tanto
disminuyeron la vulnerabilidad de las personas. Para los entrevistados en este
estudio, la ayuda proporcionada por los amigos y la familia, así como por las
organizaciones (por ejemplo; ayuda por el desarrollo), a menudo era
importante para la sobrevivencia. Alrededor de una quinta parte de los
encuestados dijeron que han recibido y proporcionado ayuda, y muchos
tienen a alguien que les pueda proveer apoyo económico o emocional. Sin
embargo, un tercio de los encuestados reportó que no se sentía que tenían a
alguien a quien recurrir en busca de apoyo material, lo que hace que a este
grupo particularmente vulnerable. Para algunos de los entrevistados, la falta
de una red de apoyo social en Nicaragua era una fuerte motivación para
migrar. Estos hallazgos son importantes ya que investigaciones anteriores han
demostrado que el apoyo social (es decir, las relaciones sociales y la
integración social de personas) es importante para la salud y para hacer frente
al estrés (por ejemplo, Turner 2004; Seeman 1996; Thoist 1995).
El tipo de ayuda más común entre la población estudiada fue las remesas; y yo
considero que las remesas son una especie de apoyo social instrumental. El
estudio cuantitativo mostró, de manera similar a otros estudios (por ejemplo,
Fajnzylber y López 2007), que casi una quinta parte de los encuestados
recibieron remesas de dinero. Los que tenían familiares en los Estados Unidos
recibieron remesas con mayor frecuencia, y los que eran trabajadores
calificados no recibieron remesas con la frecuencia que recibieron personas
con otras ocupaciones. Esto muestra una diferenciación social en los patrones
de las remesas (es decir, que los que tienen una mejor posición socio-
287
económica no reciben remesas a menudo). La mayoría de las remesas llegó
desde el extranjero, pero el 14% recibió remesas enviadas desde otros lugares
de Nicaragua. Por otra parte, a pesar de que la mayoría utiliza las remesas para
el consumo diario, casi una cuarta parte utiliza estos recursos para fines de
salud, y 13% los usa para la educación. Estos son resultados importantes que
muestran que tanto el apoyo cercano y lejano pueden mejorar el acceso de la
población a la atención de la salud y a las medicinas; así como influir en la
salud de manera indirecta a través de la mejora de las condiciones materiales
de las personas (por ejemplo, alimentos, vivienda y educación).
Las entrevistas a profundidad mostraron una imagen diversa de cómo las
remesas son importantes para la economía del hogar. En algunos casos, el
dinero enviado desde el extranjero o desde otros lugares dentro de Nicaragua
fue de suma importancia para acceder a tratamiento durante periodos de
crisis en salud. El estudio cuantitativo también mostró que las remesas fueron
importantes durante los períodos de enfermedad; ya sea en forma de
medicina, o en forma de dinero que se utilizó para comprar medicinas o
atención médica privada. Estos resultados apuntan a lo que otros estudios han
mostrado anteriormente, es decir, que el acceso a la salud y las medicinas en
Nicaragua es social y geográficamente diferenciado (Ángel-Urdinola, Cortez y
Tanabe 2008). El estudio cuantitativo también mostró que sólo el 12% de los
encuestados tenía acceso a la seguridad social, lo que hace que las remesas
sean un recurso vital ya que los que carecen de seguro social a menudo tienen
un acceso limitado a la atención de salud en Nicaragua. Las remesas que se
enviaron durante los períodos de enfermedad procedían en su mayoría de
otros lugares dentro de Nicaragua, lo que demuestra que las redes sociales
locales fueron más importantes en este caso que las redes transnacionales.
Bajo estas circunstancias, con altos niveles de pobreza, con dificultades para
ganarse la vida, con poco acceso a la seguridad social, y con un régimen social
excluyente, los recursos provenientes de la migración (es decir, las remesas)
se convierten para muchos nicaragüenses en una forma de compensar el
deficiente sector público Nicaragüense (Fouratt 2014). Algunos sostienen que
cuando las familias utilizan las remesas para acceder a los servicios en el sector
privado participan en la “privatización de los servicios públicos” (Hernández
y Coutin 2006; citado en Fouratt 2014: 78), poniendo dinero en las manos del
estado neoliberal y de ese modo “liberar” al estado de sus obligaciones para
con sus ciudadanos. Cuando el envío de remesas se señala como un “acto
moral” o un “acto de amor”, como se hace en muchos países de origen delos
migrantes, lo que pasa realmente es que se “oscurece cómo el Estado, al
basarse en la capitalización de remesas a pesar de las condiciones en que se
generaron, refuerza la inseguridad y la incertidumbre de los migrantes y de
sus familias que quedaron atrás” (Fouratt 2014: 78). La pregunta es si el
288
derecho de los nicaragüenses a la salud – como se estipula en la ley – se
cumple en estas condiciones, es decir, si al pueblo nicaragüense se le
garantizan sus derechos sociales como ciudadanos.
En cuanto a las posibilidades de desarrollo de las remesas, yo sostengo que las
remesas pueden conducir a mejoras para los que las reciben. Aunque algunos
consideran que el uso de las remesas para alimentos, ropa, vivienda,
educación y atención de la salud es “improductivo” y por lo tanto incapaz de
funcionar como estímulos para el desarrollo, estas inversiones son
importantes para sostener el desarrollo (por ejemplo Ashtana 2009; Ruger
2003), ya que las personas pueden experimentar efectos obvios e inmediatos
como resultado del dinero que se recibe (Jennings y Clarke 2005). Sin
embargo, las remesas no llegan a todos los nicaragüenses por igual, sobre
todo, no llegan a los más pobres. Los niveles de pobreza parecen no estar
afectados por las remesas, lo que lleva a preguntarse si las remesas pueden
contribuir al desarrollo en Nicaragua (Fajnzylber y López 2007).
Este estudio también mostró que a pesar de que algunos informantes tenían
intenciones de usar las remesas para inversiones “productivas” (por ejemplo,
negocios), lo que podría mejorar sus condiciones de vida a largo plazo, el
contexto socio-estructural (incluyendo el sector de atención sanitaria noinclusivo) no lo permitía, ya que las remesas tenían que ser invertidas para
solucionar problemas más apremiantes (por ejemplo, medicinas). Para que los
efectos del desarrollo lleguen a toda la población en Nicaragua, creo que se
deben de dar mayores transformaciones socio-económicas a nivel estructural.
Esta tesis también muestra que hay muchos aspectos negativos de la
migración (la separación familiar, los riesgos, la explotación, etc.) que deben
tomarse en cuenta cuando se habla de los efectos de desarrollo de la migración
y las remesas.
Las tensiones de la migración - la vulnerabilidad y el sufrimiento
de los migrantes
El estudio cualitativo destaco que las diferencias sociales fueron importantes
en cómo el acto de la migración fue experimentado por los migrantes, y de las
consecuencias que tuvo sobre su salud. En relación al cruce de fronteras, los
migrantes indocumentados eran especialmente vulnerables y expuestos a
altos riesgos. Las fronteras son a menudo áreas peligrosas, y el estudio mostró
cómo los migrantes pueden sufrir física y mentalmente durante el viaje. El
creciente número de muertes en la frontera México-Estados Unidos muestra
los efectos devastadores de la políticas de las fronteras (Eschbach et al 2001;
Sapkota et al 2006; Holmes 2013). En el lugar de destino, la falta de
289
documentos migratorios influyó en la salud de los migrantes y en el acceso a
la atención sanitaria. Los migrantes indocumentados experimentaron mucho
estrés por el temor de ser atrapados por la policía, y también se enfrentaron a
un acceso limitado a la atención sanitaria. Por otra parte, a menudo estuvieron
en una situación de trabajo precaria, donde los empleadores se aprovecharon
de su posición social débil, dándoles menos salario, menos protección, y
menos seguros. A pesar que los migrantes indocumentados se encontraron
inmersos en un contexto de relaciones laborales precarias, lo cual ha sido
relacionado con efectos negativos para la salud (por ejemplo, Tompa et al
2007); es importante resaltar que algunos migrantes internos experimentaron
una situación de mejoría tanto en las condiciones laborales como en términos
del acceso a la salud.
Tanto los migrantes internacionales como los internos que fueron
entrevistados en este estudio experimentaron los efectos de ser un
“extranjero” en un nuevo lugar, que implicó por ejemplo, sentimientos de
pérdida (por ejemplo, nostalgia, añoranza), algunos efectos corporales debido
a los cambios ambientales, y el estrés de ser “el otro”. Investigaciones
anteriores han demostrado que ser “el otro” (la xenofobia) y el racismo (la
discriminación de ciertos grupos) pueden producir consecuencias negativas
en la salud de los migrantes (Gatrell y Elliott 2009; Williams et al 2003;
Paradies 2006), lo que apunta a la gravedad de la situación para las personas
con este tipo de experiencias. Algunos de los entrevistados, sin embargo,
experimentaron mejoras en su entorno social, lo que también es importante
reconocer. Asimismo, algunos no experimentaron ser “el otro” debido a la
“blancura” de su piel; por lo tanto, las diferencias sociales (es decir, color de
la piel) también influyeron en la exposición a la xenofobia.
La salud de los migrantes que regresan a sus lugares de origen está
determinada por una “exposición acumulada” a los riesgos y
comportamientos durante todo el proceso de migración (Davies et al 2011).
Los entrevistados en este estudio experimentaron el proceso de volver a casa
después de la migración como algo más o menos suave, y más o menos
positivo, dependiendo de lo que había motivado la migración, las
circunstancias alrededor de la misma, las experiencias durante la migración
(por ejemplo, los riesgos, traumas), y si la migración se vivió como “éxito” o
no.
Los efectos en la salud producto de la separación y las estrategias
de afrontamiento
La migración a menudo implica la separación entre los miembros de las
familias. Las investigaciones han demostrado que la separación familiar
290
puede inducir a un gran estrés y afectar el bienestar emocional, llegando a
causar depresión tanto para los migrantes como para los familiares que
permanecen en los países de origen (por ejemplo, Silver 2011; Schmalzbauer
2004; Pribilsky 2004). Este estudio demuestra que los cambios en las
relaciones sociales debido a eventos de migración pueden causar
consecuencias directas e indirectas para la salud. Las emociones tuvieron un
papel muy importante para los entrevistados que experimentaron la
separación, lo que confirma los hallazgos de muchos estudios anteriores (por
ejemplo, Svaŝek 2008; Silver 2011; Baldassar 2008; Schmalzbauer 2004). A
pesar de que algunos entrevistados expresaron sentimientos positivos de
alivio y de empoderamiento, o sentimientos ambivalentes (por ejemplo, en
relación con las ventajas económicas de la migración, pero por otro lado el
dolor emocional por la separación), la mayoría de los entrevistados dijeron
que la separación era difícil y dolorosa, lo que implicó un alto costo
psicológico. Las entrevistas a profundidad mostraron que las relaciones entre
los cónyuges a veces se experimentan como difíciles de mantener, y que en
algunos casos la migración ha llevado al abandono y la desintegración de la
familia. Las madres transnacionales estaban en una situación particularmente
estresante porque eran responsables tanto de proporcionar ayuda material así
como el cuidado emocional de los niños que han dejado atrás (lo que
confirman investigaciones anteriores sobre “maternidad transnacional”, por
ejemplo Parreñas 2001, 2002, 2005; y Hondagneu-Sotelo y Ávila, 1997).
Asimismo, la ausencia de los padres causó cambios negativos en las relaciones
entre padres e hijos y afectó negativamente la salud infantil.
El estudio también mostró, de manera similar a estudios anteriores (por
ejemplo, Baldassar y Merla 2013; Schmalzbauer 2008), que se emplearon
diferentes estrategias para mantener las relaciones dentro de las familias
divididas, es decir, para hacer frente a la separación. Dentro de las estrategias
más importantes de afrontamiento o de “cuidado transnacional” (Baldassar y
Merla 2013), están tratar de mantener las relaciones a través de la
comunicación, las visitas, y tratar de aprovechar la mayor parte del tiempo
para estar juntos durante las visitas, hacer planes juntos, tratar de mantener
una actitud positiva manteniendo la Fe, y expresar el cuido a través del envío
de remesas. El estudio cuantitativo mostró que la mayoría de los migrantes se
mantuvo en contacto con los miembros de su familia, lo cual es positivo ya que
los resultados cualitativos mostraron que el contacto podría ser muy
importante para hacer frente a la separación. Es importante destacar que el
7% no tiene ningún contacto en absoluto con los migrantes, y que alrededor
de un quinto sólo tenía contacto un par de veces al año, lo que podría hacer
más difícil la experiencia de migración.
291
Al igual que en investigaciones anteriores, nuestro estudio cuantitativo
mostró que había un gradiente social en el estado de la salud de los individuos;
las personas pobres con menos frecuencia calificaron su estado de salud física
como “buena” que las personas no pobres. El estudio cuantitativo también
mostró que la migración tuvo un efecto en la autopercepción de la salud física,
ya que los “dejados atrás” (los miembros de la familia de los emigrantes) – y
en especial los que tenían familiares en el extranjero que carecían de estatus
migratorio legal – tenían menos probabilidades que calificaran su salud física
como “buena”.
Al igual que en estudios anteriores, el apoyo emocional percibido fue
importante para conocer cómo fue calificada la salud mental por los
encuestados; aquellos que percibían que tenían a alguien a quien recurrir en
busca de apoyo emocional con más frecuencia calificaron su estado de salud
mental como “bueno”. Sin embargo la salud mental, parece no ser afectada
por los eventos migratorios. Esto contradice los hallazgos cualitativos que
mostraron que los familiares de los migrantes a menudo experimentan
angustia emocional. Estos hallazgos muestran las ventajas de usar un enfoque
de métodos mixtos de investigación.
Ventajas y desventajas
Este estudio ha demostrado que la relación entre migración y la salud podría
ser tanto positiva como negativa. A través de la migración, las mujeres podían
ver el fin de la violencia física y el abuso sexual. Los migrantes internos a
menudo mejoraron su acceso a la salud y los medicamentos. Asimismo, las
vulnerabilidades relacionadas con eventos naturales impredecibles pudieron
evitarse a través de la migración. A través del dinero producto del trabajo del
migrante, la vida cotidiana y la salud de las personas se podrían mejorar, en
términos de una mejor nutrición, vivienda y acceso a la educación, atención
de la salud y la medicina. La salud podría, sin embargo, también verse afectada
negativamente por la migración. Tanto los migrantes internos e
internacionales experimentaron estrés mientras se movían a un lugar nuevo.
Algunos migrantes internacionales experimentaron dificultades para acceder
a la asistencia sanitaria en el lugar de destino. La vulnerabilidad, el estrés, las
experiencias y sufrimientos de los migrantes sin embargo variaron; los
migrantes indocumentados enfrentan una situación particularmente
estresante, tanto durante el transcurso del viaje como en el destino, lo que
también podría influir en la salud. Algunos migrantes internacionales también
habían experimentado el estrés de las situaciones precarias y peligrosas de
trabajo y la xenofobia. Por otra parte, muchos de los que fueron separados de
sus familias debido a la migración experimentaron sufrimiento mental. De
hecho, miembros de la familia que dejaron atrás no calificaron su salud física
292
tan buena con la misma frecuencia que los que no experimentan la separación
debido a la migración. Para todos, la migración involucró tanto ventajas como
desventajas para la salud, sin embargo las desventajas a veces pueden
producir efectos muy graves sobre la salud física y mental. Las diferencias
sociales para los indocumentados, así como el color de la piel fueron decisivos
en cómo la experiencia de la migración fue tomando forma.
*
*
*
*
*
*
*
Empecé esta tesis con la presentación de las historias de dos migrantes de
América Latina - Carmen de Bolivia y José Luis de Honduras. Sus relatos
ponen de manifiesto que las experiencias de los entrevistados y los
encuestados en esta tesis no son exclusivos para los nicaragüenses, son
también relevantes en otros contextos con características similares. De
acuerdo con Jennings y Clarke (2005) llego a la conclusión de que las
decisiones de quienes migran en las circunstancias de las desigualdades
globales, las relaciones de trabajo precarias, y los sistemas de atención de
salud no inclusivas a menudo implican una elección entre dos malas opciones
– seguir siendo pobres, marginados y con pocos recursos para atender a las
necesidades de atención de la salud, o correr el riesgo de la migración y
soportar el dolor emocional de la separación de los seres queridos con el fin
de tener una vida mejor en el futuro. Es crucial reconocer la situación de las
personas involucradas en este proceso. A pesar de algunos de los efectos
positivos de esta experiencia, esta tesis ha demostrado que la migración tiene
muchos efectos negativos para la salud de los migrantes y de sus familiares
que se quedan en los países de origen. Para los migrantes y las familias
migrantes los derechos sociales y de la salud son por lo tanto los temas de
mayor preocupación. La necesidad de una “ciudadanía médica” que garantice
el derecho de todo ser humano a la salud, independientemente de la
nacionalidad o de la residencia nacional, es más urgente que nunca y es una
cuestión de justicia social que sólo puede encontrar soluciones globales.
293
Sammanfattning på svenska
Denna avhandling består av totalt åtta kapitel, indelade i tre delar – en
introducerande, en empirisk och en avslutande del.
Del ett inleds med Kapitel 1 som introducerar avhandlingsämnet – relationen
mellan migration och hälsa (eng: ”the migration-health nexus”), samt
forskningsfältet hälsogeografi som denna avhandling är placerad inom.
Kapitlet redogör för studiens övergripande målsättning: att kritiskt utforska
och analysera kopplingar mellan migration och hälsa i samtida Nicaragua.
Här framkommer att studien undersöker både hur migration påverkar hälsa
och hur hälsa påverkar migration, samt att hälsofrågor spåras inom hela
migrationsprocessen, inklusive förhållanden på ursprungsplatsen och i
destinationen, under resorna och efter återvändandet, samt situationen för
både migranter och deras familjemedlemmar. Kapitlet beskriver även
forskningssamarbetet mellan Umeå, Sverige och León, Nicaragua som denna
studie gjordes inom ramen för, och det befolkningsbaserade datasystemet,
innehållande hälso- och demografiska enkätdata (eng: ”Health and
Demographic Surveillance System”, HDSS) som användes i studien.
Kapitel 2 presenterar avhandlingens teoretiska ramverk och diskuterar
teoretiska perspektiv och analytiska koncept gällande hälsa och migration:
sociala och geografiska perspektiv på hälsa, samt relationella och
transformativa perspektiv på migration, inklusive de centrala begreppen
mobila försörjningsstrategier (eng: ”mobile livelihoods”) och translokala
geografier (eng: ”translocal geographies”). Det diskuterar även speciellt
viktiga områden för denna avhandling, bland annat den ”globaliserade”
kroppen, migranters hälsa, samt transnationella familjer och hälsa.
Kapitel 3 beskriver avhandlingens empiriska material samt diskuterar de
metoder och analysstrategier som använts i studien. Avhandlingen bygger på
en fallstudie av migration och hälsa i Nicaragua och en kombination av
kvalitativa och kvantitativa material som insamlats under fältarbete under
åren 2006 till 2008 (med ett uppföljningsbesök 2013), på två platser i
Nicaragua (staden León och landsbygdsområdet Cuatro Santos; se karta sid.
x). Biografiska djupintervjuer med 17 män och kvinnor (15 inspelade)
genomfördes som sedan analyserades genom konstruktivistisk grundad teori
och det biografiska angreppssättet. En enkätstudie genomfördes även i två
steg inom ramen för det befintliga enkätdatasystemet (HDSS); antalet
respondenter i det andra steget (2008) var 1383 (572 i León och 811 i Cuatro
Santos). Enkätdatat analyserades genom deskriptiv statistik och binär
logistisk regressionsanalys.
294
Kapitel 4 ger en historisk och nutida skildring av Nicaragua och de två
studieområdena, det vill säga kontexten för relationerna mellan migration och
hälsa som analyseras i avhandlingen. Jag visar i kapitlet hur relationerna
mellan migration och hälsa är kopplade till socioekonomiska och politiska
faktorer som tagit form under Nicaraguas historia, som präglats av
kolonisering och neo-kolonisering, diktatur och revolution, inbördeskrig och
Contra-krig, samt nyliberalism och strukturanpassningar. Dagens
migrationsmönster har djupa historiska rötter, kopplade till dessa
socioekonomiska och politiska omvandlingar. Sedan 1990-talet är det allt fler
Nicaraguaner som flyttar utomlands för att försörja sig, och transnationella
relationer och splittrade familjer har därmed blivit vanligare, liksom
remittanser (pengar som migrantarbetare skickar hem). På grund av att
hälsosystemet är dåligt utbyggt och privatpersoner tvingas betala en stor del
av kostnaderna för hälsovård ur egen ficka är det även vanligt att remittanser
används för dessa syften.
Del två – den empiriska delen – tar därefter vid och inleds med en
introduktion som visar på komplexiteten i relationerna mellan hälsa och
migration och att olika erfarenheter ofta överlappar varandra under livets
gång. Här presenteras också de tre övergripande temana som identifierades i
den kvalitativa analysen och som utgör grunden för de tre empiriska kapitlen
– mobila försörjningsstrategier, migranters hälsa och translokala liv.
Dessutom redogörs för tre viktiga aspekter som genomsyrar de övergripande
temana – sårbarhet, lidande och hanteringsstrategier (eng: ”vulnerability”,
”suffering” och ”coping”). Eftersom dessa aspekter var mer eller mindre
utmärkande för olika personer så betonar jag vikten av kontextualisering och
förståelsen för sociala skillnader (till exempel social klass, hudfärg och
immigrantstatus).
Kapitel 5 ägnas åt temat mobila försörjningsstrategier och analyserar
studiedeltagarnas migrationsmönster och hälsa i relation till
migrationsprocessen. Kapitlet visar att både migration och migrationsnätverk
är vanligt förekommande i studieområdena. Internationella migranter flyttar
huvudsakligen till Costa Rica och USA, men i Cuatro Santos var det även
vanligt att ha släktingar i Honduras och El Salvador. Det kvalitativa materialet
visade att migrationsnätverk ibland bidrog till nya flyttningar. Ekonomiska
motiv till migration var vanliga i både enkät- och intervjumaterialet. I
intervjuanalysen identifierades två centrala faktorer bakom flyttingar – för att
försörja sig och sina hushållsmedlemmar (mobila försörjningsstrategier),
samt strävan efter att förbättra livsförhållandena (spanska: ”seguir adelante”).
Även om ekonomiska motiv betonades i studien så visade intervjuerna på en
komplexitet i beslutsprocessen. Människor flyttade även för sociala skäl, i
utbildningssyfte samt av hälsorelaterade skäl (eller för att tjäna pengar som
295
kunde täcka kostnader för utbildning, hälsovård och mediciner). En central
slutsats i kapitlet är att hälsofrågor ofta var direkt eller indirekt inbäddade i
andra skäl. Även genusrelationer och speciellt kvinnors situation lyftes i
kapitet, till exempel att det omfattande våldet mot kvinnor påverkar
migrationsbeslut, samt att kvinnor ibland måste migrera för att hitta ett sätt
att försörja sig efter att ha blivit lämnade med allt ansvar för barnen, och
därmed också måste utstå smärtan med att leva skilda från sina barn. I
kapitlet diskuteras även vikten av sociala nätverk och translokalt socialt stöd
för att klara sig i de tuffa Nicaraguanska levnadsförhållandena, samt för
hälsan och tillgången till hälsovård och medicin. Många var beroende av hjälp
från andra, och hjälpte även i sin tur andra, men en stor del upplevde att de
saknade någon att vända sig till vid behov. Intervjuerna visade att bristen på
hjälp från andra ibland låg bakom migrationsbeslut. Socialt stöd är viktigt för
att kunna hantera stress vilket gör dessa resultat särskilt betydelsefulla.
Kapitlet visade att remittanser – speciellt pengaremittanser – var den
vanligaste sortens hjälp som togs emot av studiedeltagarna. Dessa skickades
framför allt från personer boende i andra länder, men också från andra platser
i Nicaragua, vilket innebär att translokala sociala nätverk var viktiga för
studiedeltagarnas sociala stöd. Enkätrespondenterna som hade släktingar i
USA tog oftare än andra emot remittanser, samt de som inte hade ett mer
kvalificerat arbete (det vill säga icke-kvalificerade arbetare, hemmafruar,
studenter, arbetslösa, pensionärer och handikappade), vilket visade att sociala
skillnader fanns mellan remittansmottagarna och andra. De flesta använde
remittanserna för att betala vardagsutgifter (till exempel mat och
boendekostnader), och nästan en fjärdedel använde dem för att betala
kostnader för hälsovård. Remittanser var med andra ord viktiga för att säkra
människors tillgång till hälsovård, samt för att förbättra levnadsförhållanden
som indirekt är viktiga för hälsan. Intervjuerna visade hur viktigt detta stöd
kunde vara vid akut sjukdom, till exempel för att göra nödvändiga
undersökningar, behandlingar och för att köpa nödvändig medicin. Endast en
liten del av enkätrespondenterna hade dessutom socialförsäkring, vilka
generellt är viktiga för människors tillgång till hälsovård i Nicaragua. Studien
visar sammantaget att sociala skillnader finns i människors tillgång till
hälsovård och medicin och att hjälpen inom translokala sociala nätverk är
viktig och ibland avgörande för människors hälsa.
Kapitel 6 behandlar konsekvenser av och hälsoeffekter med flyttningar ur
migranternas perspektiv. Vi får i kapitlet följa migranter längs deras väg –
under resorna, på den nya platsen, samt efter återvändandet hem – och se hur
migranter påverkas och hur svårigheter under migrationsprocessen hanteras.
Även om en del intervjupersoner upplevde förbättringar – till exempel i den
sociala miljön efter att ha lämnat destruktiva familjeförhållanden, och i
tillgången till hälsovård efter att ha flyttat från landsbygden till staden i
296
Nicaragua – så framkom i intervjuerna att många upplevde en stor stress med
att flytta. En del hade svårigheter med att leva på en ny plats på grund av
hemlängtan och saknaden av familjemedlemmar. Internationella migranter
erfar kroppsliga effekter på grund av förändringar i klimat och matvanor, samt
stress och lidande på grund av främlingsfientlighet, rasism och
diskriminering. De som korsade gränser ”illegalt” var utsatta för mycket stress
och riskfyllda situationer och erfar ibland stort lidande. De papperslösa
upplevde även stora svårigheter i det nya landet, till exempel gällande
arbetssituation, boendeförhållanden och tillgången till hälsovård. En viktig
slutsats är därför att sociala skillnader (t.ex. immigrantstatus och hudfärg) är
av yttersta vikt för migranters sårbarhet och lidande. Återvändandet
upplevdes olika beroende på omständigheterna som omgärdade migrationen.
En del var glada att återvända till efterlängtade familjemedlemmar, andra var
ambivalenta efter att ha lyckats åstadkomma det de hade för avsikt att göra
men samtidigt saknade möjligheten att arbeta, och vissa återvände med en
känsla av skam och sorg efter att ha ”misslyckats” med att förverkliga sina
drömmar och efter att ha utstått smärtsamma situationer.
Kapitel 7 fokuserar på hur sociala relationer förändras vid migration, framför
allt på konsekvenser för relationen mellan migranter och deras
familjemedlemmar samt resulterande hälsoeffekter. Det berör också hur
studiedeltagarna hanterar separationen inom familjen. Studien visar att både
direkta och indirekta hälsoeffekter orsakades av separationen inom familjer.
Intervjerna visade hur känslomässigt påverkade migranterna och deras
familjemedlemmar var av separationen. Även om några upplevde positiva
känslor, till exempel mindre rädsla eller glädje för det positiva som
migrationen gav (ökade inkomster), så visade studien att många upplevde oro,
saknad och djup sorg på grund av separationen från familjemedlemmar.
Familjerelationer påverkades också; i yttersta fall upplöstes familjen när män
övergav sina fruar och barn. Barns psykiska och fysiska hälsa påverkades i
vissa fall väldigt negativt på grund av separationen från föräldrar.
Enkätstudien visade att familjemedlemmar till migranter (eng: ”leftbehinds”) – och i synnerhet de som hade papperslösa migranter i familjen –
oftare skattade sin fysiska hälsa som dålig än de som inte hade några
migranter i familjen. Självskattad fysisk hälsa påverkades med andra ord
negativt av migration. Studien visar även att olika strategier användes för att
hantera separationen. De mest framträdande var att försöka bibehålla
relationerna genom telefonsamtal och besök, att göra det mesta av situationen
(utnyttja tiden tillsammans), att göra gemensamma planer, att försöka vara
positiv och bibehålla tron på att allt ordnar sig, samt att utrycka sin omsorg
genom att försörja familjen och skicka remittanser. Dessa strategier kan ses
som sätt att visa och utföra omsorg translokalt.
297
Del 3 summerar och diskuterar studiens viktigaste resultat. Förutom det som
nämnts i ovanstående kapitelsummeringar så diskuterar kapitel 8 bland
annat att kopplingarna mellan migration och hälsa i studien är av både positiv
och negativ karaktär. Till exempel kan våld mot kvinnor upphöra tack vare
migration, interna migranter kan få en förbättrad tillgång till hälsovård, och
pengarna som migrantarbetare tjänar kan leda till bättre levnadsförhållanden
och förbättrad tillgång till hälsovård, medicin och utbildning. Men,
människors hälsa kan också påverkas negativt i och med migrationshändelser.
Till exempel kan migranter utsättas för riskfyllda och stressande situationer,
och internationella migranter kan erfara en begränsad tillgång till hälsovård,
samt utanförskap och diskriminering. De papperslösa migranterna var
speciellt sårbara och genomled mer stress och lidande, liksom de med
mörkare hudfärg. En slutsats i avhandlingen är således att migration kan leda
till både fördelar och nackdelar för hälsa och att socio-strukturella faktorer
påverkar utkomsten av relationen till stor utsträckning. I slutkapitlet
diskuteras även möjligheterna för remittanser att bidra till socioekonomisk
utveckling i Nicaragua. Avhandlingen visar att remittanser är viktiga för en
stor del av befolkningen och att de ofta används för sådant som direkt och
indirekt kan bidra till positiva effekter. Men, eftersom inte alla får ta del av
dessa remittanser så hävdar jag att större socioekonomiska reformer behöver
äga rum i landet, speciellt inom hälsosektorn, för att utvecklingen ska komma
hela befolkningen till del. I dagsläget kompenserar remittanser för bristerna i
den offentliga sektorn, och den Nicaraguanska befolkningens hälso- och
sociala rättigheter är på långt när uppfyllda. Dessutom följer stora negativa
konsekvenser för de som migrerar och för deras familjemedlemmar vilket
måste tas i beaktande när utvecklingsmöjligheterna med migration
diskuteras. I dagsläget står människor inför valet att stanna kvar och fortsätta
leva i fattigdom med begränsad möjlighet att tillfredsställa hälsobehov, eller
att flytta och utstå risker, stress och smärta på grund av splittrade
familjerelationer för att få ett bättre liv. Migranters och migrantfamiljers
hälso- och sociala rättigheter är en fråga om social rättvisa som förtjänar
större uppmärksamhet och en global lösning.
298
References
Acemoglu, Daron and Johnson, Simon (2006) Disease and Development: The
Effect of Life Expectancy on Economic Growth, Working Paper 12269,
National Bureau of Economic Research, Cambridge. Available online:
http://www.nber.org/papers/w12269
Adazu, Kubaje; Feiken, Daniel; Ofware, Peter; Onyango, Bernard; Obor,
David; Kiriinya, Rose; Slutsker, Laurence; Vulule, John; and Laserson, Kayla
(2009) “Child Migration and Mortality in Rural Nyanza Province: Evidence
from the Kisumu Health and Demographic Surveillance System (KHDSS) in
Western Kenya”, in: Collinson, M., Adazu, K., White, M., and Findley, S. (eds.)
The Dynamics of Migration, Health and Livelihoods. INDEPTH Network
Perspectives, Ashgate Publishing: Farnham
Aguilar, Jeannette and Carranza, Marlon (2008) Las Maras y Pandillas como
Actores Ilegales de la Región [Las Maras and Gangs as Illegal Actors in the
Region], Informe Estado de la Región 2008 [Report on the State of the
Region], San Salvador
Agyei-Mensah, Samuel and de-Graft Aikins, Ama (2010) Epidemiological
Transition and the Double Burden of Disease in Accra, Ghana, Journal of
Urban Health, vol. 87, no. 5, pp. 879-897
Ahmed, Sara (2000) Strange Encounters: Embodied Others in PostColoniality, Routledge: London
Alba, Francisco and Castillo, Ángel Manuel (2012) New Approaches to
Migration Management in Mexico and Central America, The Regional
Migration Study Group, Migration Policy Institute: Washington
Alcántara-Ayala, Irasema (2002) Geomorphology, natural hazards,
vulnerability and prevention of natural disasters in developing countries,
Geomorphology, vol. 47, no. 2-4, pp. 107-124
Anderson, Kay and Smith, Susan J. (2001) Emotional Geographies,
Transactions of the Institute of British Geographers, vol. 26, no. 1, pp. 7-10
Andrews, Gavin J.; Evans, Joshua; Dunn, James R.; and Masuda, Jeffrey R.
(2012) Arguments in Health Geography: On Sub-Disciplinary Progress,
Observation, Translation, Geography Compass, vol. 6, no. 6, pp. 351-383
Angel-Urdinola, Diego F.; Cortez, Rafael; and Tanabe, Kimie (2008) Equity,
Access to Health Care Services and Expenditures on Health in Nicaragua,
Health, Nutrition and Population (HNP) Discussion Paper, The International
Band for Reconstructions and Development/The World Bank: Washington
Anna, Timothy (1985) “The Independence of Mexico and Central America”,
in: Bethell, L. (ed.) The Cambridge History of Latin America, Volume III,
Cambridge University Press: Cambridge
Anthamatten, Peter and Hazen, Helen (2011) An Introduction to the
Geography of Health, Routledge: London/New York
299
Antonovsky, Aaron (1979) Health, Stress, and Coping: New Perspectives on
Mental and Physical Well-Being, Jossey-Bass Inc.: San Franscisco
Aragão-Lagergren, Aida (1997) Working Children in the Informal Sector in
Managua, Dissertation, Department of Social and Economic Geography,
Uppsala University, Geografiska Regionsstudier no. 31
Arvidsson, Alf (1998) Livet som berättelse: studier i levnadshistoriska
intervjuer, Studentlitteratur: Lund
Ashtana, Sahil (2009) Health and Development, International Encyclopedia
of Human Geography, pp. 28-34, Elsevier Ltd
Asis, Maruja Milagros B.; Huang, Shirlena; and Yeoh, Brenda S.A. (2004)
When the lights of the family is abroad: unskilled female migration and the
Filipino family, Singapore Journal of Tropical Geography, vol. 25, no. 2, pp.
198-215
Baldassar, Loretta (2007) Transnational Families And The Provision Of Moral
And Emotional Support: The Relationship Between Truth And Distance,
Identities: Global Studies in Culture and Power, vol. 14, no. 4, pp. 385-409
Baldassar, Loretta (2008) Missing Kin and Longing to be Together: Emotions
and the Construction of Co-presence in Transnational Relationships, Journal
of Intercultural Studies, vol. 29, no. 3, pp. 247-266
Baldassar, Loretta and Merla, Laura (2013) “Introduction: Transnational
Family Caregiving Through the Lens of Circulation”, in: Baldassar, L. and
Merla, L. (eds.) Transnational Families, Migration and the Circulation of
Care: Understanding Mobility and Absence in Family Life, Routledge
Research in Transnationalism, Routledge: New York/Milton Park
Barbalet, Jack (ed.) (2002) Emotions and Sociology, Blackwell Publishing:
Oxford
Barnes, Trevor J. (2009) ‘Not only . . . but also’: Quantitative and critical
geography, Professional Geographer, vol. 61, no. 3, pp. 292–300
Barraclough, Solon I. and Scott, Michael F. (1987) ‘The rich have already
eaten…’ Roots of catastrophe in Central America, Transnational Issues Series
#3, Transnational Institute: Amsterdam
Bauman, Zygmunt (2000) Globalisering, [Globalization], Studentlitteratur:
Lund
Bauman, Zygmunt (1998) On glocalization: or globalization for some, and
localization for some others, Thesis Eleven, vol. 54, no. 1, pp. 37-49
Benmayor, Rina and Skotnes, Andor (1994) International yearbook of oral
history and life stories, Vol. 3, Migration and identity, Oxford University
Press: New York
Bethell, Leslie (ed.) (1985) The Cambridge History of Latin America, Volume
III-V, Cambridge University Press: Cambridge
300
Bhugra, Dinesh and Becker, Matthew A. (2005) Migration, cultural
bereavement and cultural identity, World Psychiatry, vol. 4, no. 1, pp. 18-24
Binational Migration Institute (2013) A Continued Humanitarian Crisis at
the Border: Undocumented Border Crosser Deaths Recorded by the Pima
County Office of the Medical Examiner, 1990-2012, Binational Migration
Institute, University of Arizona, Department of Mexican American Studies,
June 2013
Boccagni, Paolo (2012) Practising Motherhood at a Distance: Retention and
Loss in Ecuadorian Transnational Families, Journal of Ethnic and Migration
Studies, vol. 38, no. 2, pp. 261-277
Boehm, Deborah A. (2011) Deseos y Dolores: Mapping Desire, Suffering, and
(Dis)loyalty within Transnational Partnerships, International Migration, vol.
49, no. 6, pp. 95-106
Bonacich, Edna; Alimahomed, Sabrina; and Wilson, Jake B. (2008) The
Racialization of Global Labor, American Behavioral Scientist, vol. 52, no. 3,
pp. 342-355
Boyle, Paul; Halfacree, Keith; and Robinson, Vaughan (1998) Exploring
contemporary migration, Addison Wesley Longman: Harlow
Brabant, Zoé and Raynault, Marie-France (2012) Health Situation of Migrants
with Precarious Status: Review of the Literature and Implications for the
Canadian Context - Part A, Social Work in Public Health, vol. 27, no. 4, pp.
330-344
Braveman, Paula and Siegel, David (1987) Nicaragua: A health system
developing under conditions of war, International Journal of Health
Services, vol. 17, no. 1, pp. 169-178
Brickell, Katherine and Datta, Ayona (eds.) (2011) Translocal geographies:
Spaces, Places, Connections, Ashgate: Farnham
Brown, Tim; McLafferty, Sara; and Moon, Graham (2010) A companion to
health and medical geography, Blackwell Companions to Geography, No. 8,
Wiley-Blackwell: Oxford
Brown, Anna and Patten, Eileen (2013) Hispanics of Nicaraguan Origin in
the United States, 2011, Statistical Profile, Pew Research Center/Pew
Hispanic Center: Washington
Bubandt, Nils and Otto, Ton (2010) “Anthropology and the Predicaments of
Holism”, in: Otto, T. and Bubant, N. (eds.) Experiments in Holism: Theory
and Practice in Contemporary Anthropology, Blackwell: Oxford
Burns, E. Bradford (1991) Patriarch and Folk: The emergence of Nicaragua,
1798-1858, Harvard University Press: Cambridge
Bustamente, Juan José and Alemán, Carlos (2007) Perpetuating Splithousehold Families: The Case of Mexican Sojourners in Mid-Michigan and
their Transnational Fatherhood Practices, Migraciones Internacionales, vol.
4, no. 1, pp. 65-86
301
Cabieses, Báltica and Tunstall, Helena (2013) “Socioeconomic vulnerability
and access to healthcare among immigrants in Chile”, in: Thomas, F. and
Gideon, J. (eds.) Migration, health and inequality, Zed Books: London/New
York
Cabieses, Báltica; Tunstall, Helena; Pickett, Kate E; and Gideon, Jasmine
(2013) Changing patterns of migration in Latin America: how can research
develop intelligence for public health? Revista panamericana de salud
pública, vol. 34, no. 1, pp. 68-74
Caldera Aburto, Trinidad J. (2004) Mental health in Nicaragua: with special
reference to psychological trauma and suicidal behaviour, Dissertation,
Umeå University, Department of Clinical Sciences, Division of Psychiatry
Callahan, Daniel (2012) “The WHO Definition of Health”, Chapter 5 in: The
Roots of Bioethics: Health, Progress, Technology, Death, Oxford University
Press: Oxford
Carballo, Manuel and Mboup, Mourtala (2005) International migration and
health, paper prepared for the Policy Analysis and Research Programme of the
Global Commission on International Migration, International Centre for
Migration and Health
Cardoso, Ciro F. S. (1985) “Central America: the Liberal Era, c. 1870-1930”,
in: Bethell, L. (ed.) The Cambridge History of Latin America, Volume V,
Cambridge University Press: Cambridge
Carling, Jørgen; Menjívar, Cecilia; and Schmalzbauer, Leah (2012) Central
Themes in the Study of Transnational Parenthood, Journal of Ethnic and
Migration Studies, vol. 38, no. 2, pp. 191-217
Castañeda, Ernesto and Buck, Lesley (2011) Remittances, Transnational
Parenting, And The Children Left Behind: Economic And Psychological
Implications, The Latin Americanist, vol. 55, no. 4, pp. 85-110
Castillo, Manuel Á. (2001) Tendencias y Determinantes Estructurales de la
Migración Internacional en Centroamérica [Trends and Structural
Determinants of International Migration in Central America], in: Bixby, L. R.
(ed.) Población del Istmo 2000: Familia, migración, violencia y medio
ambiente [Population of the Isthmus 2000: Family, migration, violence and
environment], Universidad de Costa Rica, Centro Centroamericano de
Población [University of Costa Rica, the Central American Population Center],
Universidad de Costa Rica: San José
Castles, Stephen (2010) Understanding Global Migration: A Social
Transformation Perspective, Journal of Ethnic and Migration Studies, vol.
36, no. 10, pp. 1565-1586
Castles, Stephen; de Haas, Hein; and Miller, Mark J. (2013) The age of
migration: International Population Movements in the modern world, 5th
edition, Palgrave Macmillan: Basingstoke
CEPAL (2011) Nicaragua: Evolución economica durante 2010 y perspectivas
para 2011 [Nicaragua: Economic development during 2010 and prospects for
302
2011], Comisión Económica para América Latina (CEPAL) [the United
Nations Economic Commission for Latin America and the Caribbean], UNCEPAL: México
Chant, Sylvia and McIlwaine, Cathy (2009) Geographies of Development in
the 21st Century: An Introduction to the Global South, Edward Elgar:
Cheltenham/Northhampton
Charmaz, Kathy (2003) “Grounded Theory: Objectivist and Constructivist
Methods”, in: Denzin, N. and Lincoln, Y. (eds.) Strategies of Qualitative
Inquiry, Part II of Handbook of Qualitative Research, 2nd edition, Sage:
Thousand Oaks/London/New Delhi
Coburn, David (2000) Income inequality, social cohesion and the health
status of populations: the role of neo-liberalism, Social Science & Medicine,
vol. 51, no. 1, pp. 135-146
Coburn, David (2004) Beyond the income inequality hypothesis: class, neoliberalism, and health inequalities, Social Science & Medicine, vol. 58, no. 1,
pp. 41-56
Cohen, Sheldon (2004) Social Relationships and Health, American
Psychologist, vol. 59, no. 8, pp. 676-684
Conradson, David (2005) Landscape, care and the relational self: therapeutic
encounters in rural England, Health & Place, vol. 11, no. 4, pp. 337-48
Cornelius, Wayne A. (2001) Death at the Border: Efficacy and Unintended
Consequences of US Immigration Control Policy, Population and
Development Review, vol. 27, no. 4, pp. 661-685
Crafts, Nicholas (2002) The Human Development Index, 1870-1999: Some
revised estimates, European Review of Economic History, vol. 6, no. 3, pp.
395-405
Crooks, Valorie A.; Schuurman, Nadine; Cinnamon, Jonathan; Castleden,
Heather; and Johnson, Rory (2011) Refining a Location Analysis Model Using
a Mixed Methods Approach: Community Readiness as a Key Factor in Siting
Rural Palliative Care Services, Journal of Mixed Methods Research, vol. 5, no.
1, pp. 77-95
Cruz, José Miguel (2005) “El barrio transnacional: las maras
centroamericanas como red” [The transnational neighbourhood: the Central
American gangs as network], Chapter 12 in: Pisani et al. (eds.) Redes
transnacionales en la Cuenca de los Huracanes. Un aporte a los estudios
interamericanos [Transnational networks in the Hurricane Basin. A report on
Interamerican studies], Instituto Autónomo de México, available online at:
http://www.uca.edu.sv/publica/iudop/articulos/JMC3.pdf
CSDH/WHO (2008) Closing the gap in a generation. Health equity through
action on the social determinants of health, Final Report, the Commission on
Social Determinants of Health (CSDH), World Health Organization (WHO):
Geneva
303
Curtis, Sarah (2004) Health and Inequality: Geographical Perspectives,
Sage: London
Curtis, Sarah and Riva, Mylène (2010) Health geographies I: Complexity
theory and human health. Progress in Human Geography, vol. 34, no. 2, pp.
215–223
Davidson, Joyce; Bondi, Liz; Smith, Mick (eds.) (2005) Emotional
Geographies, Ashgate: Aldershot
Davis, Kingsley and Casis, Ana (1946) Urbanization in Latin America, The
Milbank Memorial Fund Quarterly, vol. 24, no. 2, pp. 186-207
Davies, Rebecca (2007): Reconceptualising the migration-development
nexus: diasporas, globalisation and the politics of exclusion, Third World
Quarterly, vol. 28, no. 1, pp. 59-76
Davies, Anita; Borland, Rosilyne; Blake, Carolyn; and West, Haley (2011) The
Dynamics of Health and Return Migration, PLoS Med, vol. 8, no. 6: e1001046
De Haene, Lucia; Grietens, Hans; and Verschueren, Karine (2010) Holding
Harm: Narrative Methods in Mental Health Research on Refugee Trauma,
Qualitative Health Research, vol. 20, no. 12, pp. 1664-1676
De Jong, Gordon F. and Gardner, Robert W. (eds.) (1981) Migration decision
making: Multidisciplinary approaches to microlevel studies in developed
and developing countries, Pergamon: New York
Denzin, Norman K. and Lincoln, Yvonna S. (eds.) (2003) The Landscape of
Qualitative Research: Theories and Issues, Part I of Handbook of Qualitative
Research, 2nd edition, Sage: Thousand Oaks/London/New Delhi
Denzin, Norman K. and Lincoln, Yvonna S. (eds.) (2003) Strategies of
Qualitative Inquiry, Part II of Handbook of Qualitative Research, 2nd edition,
Sage: Thousand Oaks/London/New Delhi
Denzin, Norman K. and Lincoln, Yvonna S. (eds.) (2003) Collecting and
Interpreting Qualitative Materials, Part III of Handbook of Qualitative
Research, 2nd edition, Sage: Thousand Oaks/London/New Delhi
Denzin, Norman K. and Lincoln, Yvonna S. (2003) “Introduction: The
Discipline and Practice of Qualitative Research”, in: Denzin, N. and Lincoln,
Y. (eds.) Handbook of Qualitative Research, 2nd edition, Sage: Thousand
Oaks/London/New Delhi
Donato, Katharine M.; Aguilera, Michael; and Wakabayashi, Chizuko (2005)
Immigration Policy and Employment Conditions of US Immigrants from
Mexico, Nicaragua, and the Dominican Republic, International Migration,
vol. 43, no. 5, pp. 5-29
Douglas, Mary (1966) Purity and Danger: An Analysis of Concepts of
Pollution and Taboo, Routledge: London/New York
Dreher, Henry (2004) Mind-Body Unity: A New Vision for Mind-Body
Science and Medicine, Johns Hopkins University Press: Baltimore
304
Durand, John D.; Peláez, César; Thomas, D. S.; Carleton, R. O.; Baumgartner,
L.; and Lee, E.S. (1965) Patterns of Urbanization in Latin America, The
Milbank Memorial Fund Quarterly, vol. 43, no. 4, pp. 166-196
Durkheim, Emile (1966) Suicide: a study in sociology, new edition (first
published 1897), Free Press: New York
Dyck, Isabel and Dossa, Parin (2007) Place, health and home: Gender and
migration in the constitution of healthy space, Health & Place, vol. 13, no. 3,
pp. 691-701
Ehrenreich, Barbara and Hochschild, Arlie Russell (2002) Global Woman:
Nannies, Maids and Sex-Workers in the New Economy, Metropolitan Books:
New York
Ekman, Paul (1992a) Are there basic emotions?, Psychological Review, vol.
99, pp. 550-553
Ekman, Paul (1992b) An argument for basic emotions, Cognition and
Emotion, vol. 6, no. 3, pp. 169-200
Ekman, Paul (1999) “Basic Emotions”, Chapter 3 in: Dalgleish, T. and Power,
M. (eds.) Handbook of Cognition and Emotion, John Wiley & Sons Ltd.
Elliot, Susan J. and Gillie, Joan (1998) Moving experiences: a qualitative
analysis of health and migration, Health & Place, vol. 4, no. 4, pp. 327-339
Ellsberg, Mary Carroll (2000) Candies in hell: Research and action on
domestic violence against women in Nicaragua, Dissertation, Umeå
University, Epidemiology, Department of Public Health and Clinical Medicine
Emmelin, Maria; Nafziger, Anne N.; Stenlund, Hans; Weinehall, Lars; and
Wall, Stig (2006) Cardiovascular risk factor burden has a stronger association
with self-rated poor health in adults in the US than in Sweden, especially for
the lower educated, Scandinavian Journal of Public Health, vol. 34, no. 2, pp.
140-149
Eriksson, Thomas Hylland (2007) Globalization: the key concepts, Berg:
Oxford/New York
Eriksson, Malin; Dahlgren, Lars; Janlert, Urban; Weinehall, Lars; and
Emmelin, Maria (2010) Social Capital, Gender and Educational Level –
Impact on Self-Rated Health, The Open Public Health Journal, 2010, vol. 3
Eschbach, Karl; Hagan, Jacqueline; Rodriguez, Nestor; Hernandez-Leon,
Ruben; and Bailey, Stanley (1999) Death at the Border, International
Migration Review, vol. 33, no. 2, pp. 430-454
Eschbach, Karl; Hagan, Jacqueline; Rodriguez, Nestor; Hernandez-Leon,
Ruben; and Bailey, Stanley (2001) Causes and Trends in Migrant Deaths
Along the US-Mexico border, 1985-1998, University of Houston, Center for
Immigration Research
Eschbach, Karl; Hagan, Jacqueline; and Rodriguez, Nestor (2003) Deaths
During Undocumented Migration: Trends and Policy Implications in the New
305
Era of Homeland security, In Defense of the Alien, vol. 26, pp. 37-52, Centre
for Migration Studies of New York
Evans, Jeffrey (1987) Introduction: Migration and Health, International
Migration Review, vol. 21, no. 3, Special Issue: Migration and Health, pp. vxiv
Faist, Thomas (2000) The Volume and Dynamics of International Migration
and Transnational Social Spaces, Oxford University Press: Oxford
Faist, Thomas; Fauser, Margit; and Kivisto, Peter (eds.) (2011) The MigrationDevelopment Nexus: A Transnational Perspective, Palgrave Macmillan:
Basingstoke
Fajnzylber, Pablo and López, Humberto J. (2007) Close To Home: The
Development Impact of Remittances in Latin America, The International
Bank for Reconstruction and Development/The World Bank: Washington
Falcón, Sylvanna (2007) “Rape as a Weapon of War: Militarized Rape at the
U.S.-Mexico Border”, in: Segura, D. and Zavella, P. (eds.) Women and
Migration: In the U.S.-Mexican Borderlands, A Reader, Duke University
Press: Durham
Felski, Rita (2000) Nothing to Declare: Identity, Shame, and the Lower
Middle Class, PMLA, vol. 115, no. 1, Special Topic: Rereading Class, pp. 33-45
Fielding, Tony (1992) “Migration and culture”, in: Champion, T. and Fielding,
T. (eds.) Migration processes and patterns, Vol. 1, Research progress and
prospects, Belhaven Press: London
Findlay, Allan and Li, F.L.N. (1999) Methodological Issues in Researching
Migration, Professional Geographer, vol. 51, no.1, pp. 50-59
Findlay, Allan and Li, F.L.N. (1997) An auto-biographical approach to
understanding migration: the case of Hong Kong emigrants, Area, vol. 29, no.
1, pp. 34-44
Folkman, Susan (2011) The Oxford Handbook of Stress, Health and Coping,
Oxford University Press: New York
Folkman, Susan and Moskowitz, Judith Tedlie (2004) Coping: Pitfalls and
Promise, Annual Review of Psychology, vol. 55, pp. 745-774
Fontana, Andrea and Frey, James H. (2003) “The Interview: From structured
questions to negotiated text”, in Denzin, N. and Lincoln, Y. (eds.) Collecting
and Interpreting Qualitative Materials, Part III of Handbook of Qualitative
Research, 2nd edition, Sage: Thousand Oaks/London/New Delhi
Fouratt, Caitlin (2012) Por El Amor Y La Tierra: Las Inversiones Emocionales
De Los Migrantes Nicaragüenses [For Love and the Nation: the Emotional
Investments
of
Nicaraguan
migrants],
Anuario
de
Estudios
Centroamericanos, Universidad de Costa Rica, vol. 38, pp. 193-212
Fouratt, Caitlin (2014) Presences and Absences: Nicaraguan Migration to
Costa Rica and Transnational Families, Dissertation, California State
University
306
Freeman Smith, Robert (1985) “Latin America, the United States and the
European powers, 1930-1930”, in: Bethell, L. (ed.) The Cambridge History of
Latin America, Volume IV, Cambridge University Press: Cambridge
Freund, Peter E. S.; McGuire, Meredith B.; and Podhurst, Linda S. (2003)
Health, Illness, and the Social Body: A Critical Sociology, Prentice Hall:
Upper Saddle River, N.J.
Freundt, Armin; Kutterolf, Steffen; Schmincke, Hans-Ulrich; Hansteen, Thor;
et.al. (2006) Volcanic hazards in Nicaragua: Past, present, and future,
Geological Society of America Special Papers, 2006, vol. 412, pp. 141-165
García-Moreno, Claudia; Jansen, Henrica; Ellsberg, Mary; Heise, Lori; Watts,
Charlotte (2006) Prevalence of intimate partner violence: findings from the
WHO multi-country study on women’s health and domestic violence, Lancet,
vol. 368, no. 8, pp. 1260-69
Garfield, Richard M.; Frieden, Thomas; and Vermund, Sten H. (1987) Healthrelated outcomes of war in Nicaragua, American Journal of Public Health,
vol. 77, pp. 615-618
Gatrell, Anthony C. (2005) Complexity theory and geographies of health: a
critical assessment, Social Science & Medicine, vol. 60, no. 12, pp. 2661-2671
Gatrell, Anthony C. (2011) Mobilities and Health, Ashgate: Farnham
Gatrell, Anthony C. and Elliott, Susan J. (2009) Geographies of health: an
introduction, 2nd edition, Wiley-Blackwell: Singapore
Geiger, Martin and Pécaud, Antoine (2013) Migration, Development, and the
‘Migration-Development Nexus’, Population, Space and Place, vol. 19, no. 4,
pp. 369-374
Gideon, Jasmine (2013) “Access versus entitlements: health seeking for Latin
American migrants in London”, in: Thomas, F. and Gideon, J. (eds.)
Migration, health and inequality, Zed Books: London/New York
Giesbrecht, Melissa; Cinnamon, Jonathan; Fritz, Charles; and Johnston, Rory
(2014) Themes in geographies of health and health care research: Reflections
from the 2012 Canadian Association of Geographers annual meeting, The
Canadian Geographer, vol. 58, no. 2, pp. 160-167
Glick Schiller, Nina; Basch, Linda; and Blanc-Szanton, Cristina (1992)
Transnationalism: A New Analytic Framework for Understanding Migration,
Annals of the New York Academy of Sciences, vol. 645, no. 1, pp. 1-24
Glick Schiller, Nina and Faist, Thomas (eds.) (2010) Migration, Development
and Transnationalization. A critical stance, Critical Interventions, A Forum
for Social Analysis, Volume 12, Berghahn Books: New York/Oxford
Goldring, Luin and Landolt, Patricia (2011) Caught in the Work–Citizenship
Matrix: the Lasting Effects of Precarious Legal Status on Work for Toronto
Immigrants, Globalizations, vol. 8, no. 3, pp. 325-341
Graham, Elspeth; Jordan, Lucy P.; Yeoh, Brenda S. A.; Lam, Theodora;
Asis, Maruja; and Su-kamdi (2012) Transnational families and the family
307
nexus: perspectives of Indonesian and Filipino children left behind by migrant
parent(s), Environment and Planning A, vol. 44, no. 4, pp. 793–815
Greco, Monica and Stenner, Paul (2008) Emotions: A Social Science Reader,
Routledge: New York
Grewal, Inderpal and Kaplan, Caren (2001) Global Identities: Theorizing
Transnational Studies of Sexuality, GLQ: A Journal of Lesbian and Gay
Studies, vol. 7, no. 4, pp. 663-679
Guerette, Rob T. (2007) Migrant Death: Border Safety and Situational Crime
Prevention on the U.S.-Mexico Divide, LFB Scholarly Publishing LLC: New
York
Gushulak, Brian D. and MacPherson, Douglas W. (2006a) Migration
medicine and health: principles and practice, BC Decker: Hamilton
Gushulak, Brian D. and MacPherson, Douglas W. (2006b) The basic
principles of migration health: Population mobility and gaps in disease
prevalence, Emerging Themes in Epidemiology, vol. 3, no.3
Gutierrez C.; Paci P.; and Ranzani M. (2008) Making Work Pay in
Nicaragua: Employment, Growth, and Poverty Reduction, The World Bank:
Washington
de Haas, Hein (2005) International Migration, Remittances and
Development: myths and facts, Third World Quarterly, vol. 26, no. 8, pp.
1269-1284
de Haas, Hein (2010) Migration and Development: A Theoretical Perspective,
International Migration Review, vol. 44, no. 1, pp. 227-264
de Haas, Hein (2012) The Migration and Development Pendulum: A Critical
View on Research and Policy, International Migration, vol. 50, no. 3, pp. 825
Hadley, Craig (2010) The complex interactions between migration and health:
an introduction, NAPA BULLETIN, vol. 34, pp. 1-5
Halfacree, Keith H. and Boyle, Paul J. (1993) The challenge facing migration
research: the case for a biographical approach, Progress in Human
Geography, vol. 17, no. 3, pp. 333-348
Hall, Stuart (1992) “New ethnicities”, in: Donald, J. and Rattansi, A. (eds.)
‘Race’, culture and difference, Sage: London
Hamilton, Nora and Chinchilla, Norma Stoltz (1991) Central American
Migration: A Framework for Analysis, Latin American Research Review, vol.
26, no. 1, pp. 75-110
Haour-Knipe, Mary (2013) “Context and perspectives: who migrates and what
tare the risks?”, in: Thomas, F. and Gideon, J. (eds.) Migration, health and
inequality, Zed Books: London/New York
308
Hargreaves, Sally and Friedland, Jon S. (2013) “Impact on and use of health
services by new migrants in Europe”, in: Thomas, F. and Gideon, J. (eds.)
Migration, health and inequality, Zed Books: London/New York
Helgesson, Linda (2006) Getting ready for life. Life strategies of Town Youth
in Mozambique and Tanzania. Dissertation. Gerum Kulturgeografi 2006:1
Helman, Cecil G. (2007) Culture, Health and Illness, 5th edition, Hodder
Arnold: London
Herrera Rodríguez, Andrés (2006) Heaven can wait: Studies on suicidal
behaviour among young people in Nicaragua, Dissertation, Umeå
University, Department of Clinical Sciences, Division of Psychiatry
Hesse-Biber, Sharlene Nagy (2010) Mixed Methods Research: Merging
Theory with Practice, Guilford Press: New York
Hewitt, Jeanette (2007) Ethical Components of Researcher-Researched
Relationships in Qualitative Interviewing, Qualitative Health Research, vol.
17, no. 8, pp. 1149-1159
Heyman, Josiah McC. (2014) “’Illegality’ and the U.S.-Mexico Border: How It
Is Produced and Resisted”, in: Menjívar, C. and Kanstroom, D. (eds.)
Constructing Immigrant “Illegality”: Critiques, Experiences, and Responses,
Cambridge University Press: New York
Hjälm, Anna (2011) A family landscape. On the geographical distances
between elderly parents and adult children in Sweden. Dissertation. Gerum
Kulturgeografi 20011:1
Hochschild, Arlie Russell (2000) “Global care chains and emotional surplus
value”, in: Hutton, W. and Giddens, A. (eds.) On the edge: living with global
capitalism, Jonathan Cape: London
Holmes, Seth M. (2013) ‘Is it worth risking your life?’: Ethnography, risk and
death on the U.S.–Mexico border, Social Science & Medicine, vol. 99, Dec.
2013, pp. 153-161
Holt-Jensen, Arild (2009) Geography: History and Concepts, A Student’s
Guide, 4th edition, Sage: London
Hondagneu-Sotelo, Pierrette and Avila, Ernestine (1997) ‘I’m here, but I’m
there’: The Meanings of Latina Transnational Motherhood, Gender & Society,
vol. 11, no. 5, pp. 548-571
Hull, Diana (1979) Migration, adaptation, and illness: a review, Social Science
& Medicine, 13A, pp. 25-36
Hunter, Mark (2010) Beyond the male-migrant: South Africa’s long history of
health geography and the contemporary AIDS pandemic, Health & Place, 16,
pp. 25-33
ILO (2012) International Standard Classification of Occupations: ISCO-08,
Volume I: Structure, group definitions and correspondence tables,
International Labour Organization (ILO), International Labour Office:
309
Geneva, available online at: http://www.ilo.org/wcmsp5/groups/public/--dgreports/---dcomm/---publ/documents/publication/wcms_172572.pdf
IMF (2004) Nicaragua: Enhanced Initiative for Heavily Indebted Poor
Countries – Completion Point Document, March 2004, International
Monetary Fund (IMF), Country Report No. 04/72, IMF: Washington
INEC (2006) VIII Censo de Población y IV de Vivienda, 2005 [The 8th
Population Census and the 4th Household Census, 2005], Instituto Nacional
De Estadísticas y Censos (INEC) [The National Institute for Statistics and
Censuses] (currently INIDE). Available at: http://www.inide.gob.ni/
INIDE (2007a) Anuario Estadístico 2007 [Statistical Yearbook 2007],
Instituto Nacional De Información De Desarrollo (INIDE) [the National
Institute for Information and Development], Nicaragua: Managua. Available
at: http://www.inide.gob.ni/Anuarios/Anuario2007.pdf
INIDE (2007b) Informe General: Encuesta de Hogares sobre Medición del
Nivel de Vida 2005 [General Report: the household survey on living standards
2005], Instituto Nacional De Información De Desarrollo (INIDE) [the
National Institute for Information and Development], Nicaragua: Managua
INIDE (2008) The Nicaraguan demographic and health survey 2006/2007,
Instituto Nacional De Información De Desarrollo (INIDE) [the National
Institute for Information and Development], Nicaragua: Managua
INIDE (2011) Encuesta de hogares sobre medición del nivel de vida 2009.
Principales resultados: pobreza, consumo, ingreso [Household survey on
living standards 2009. Main results: poverty, consumtion, income], Instituto
Nacional De Información De Desarrollo (INIDE) [the National Institute for
Information and Development], Nicaragua: Managua
IOM (2005) Health and migration: bridging the gap, International Dialogue
on Migration, No. 6, International Organization for Migration (IOM),
Migration Policy and Research Programme: Geneva
IOM (2013) Perfil Migratorio de Nicaragua 2012 [Migration Profile for
Nicaragua 2012], International Organization for Migration (IOM): Managua
Jackson, Shirley A. (ed.) (2014) Routledge International Handbook of Race,
Class and Gender, Routledge: Milton Park/New York
James, Veronica and Gabe, Jonathan (eds.) (1996) Health and the sociology
of emotions, Blackwell Publishers: Oxford
Jatrana, Santosh; Graham, Elspeth; and Boyle, Paul (2005) “Introduction:
understanding migration and health in Asia”, in: Jatrana, S., Toyota, M. and
Yeah, B. (eds.) Migration and Health in Asia, Routledge: New York
Jennings, Allen and Clarke, Matthew (2005) The Development Impact of
Remittances to Nicaragua, Development in Practice, vol. 15, no. 5, pp. 685691
Jensen, Tommy and Tollefsen, Aina (2012) Globalisering, [Globalization],
Liber: Malmö
310
Johansson, Anna (1999) La Mujer Sufrida – the Suffering Woman:
Narratives on Femininity among Women in a Nicaraguan barrio,
Monograph from the Department of Sociology, Göteborg University, no. 70
Johnson, Burke R. and Onwuegbuzie, Anthony J. (2004) Mixed Methods
Research: A research paradigm whose time has come, Educational
Researcher, vol. 33, no. 7, pp. 14-26
Johnson, Burke R.; Onwuegbuzie, Anthony J.; and Turner, Lisa A. (2007)
Toward a Definition of Mixed Methods Research, Journal of Mixed Methods
Research, vol. 1, no. 2, pp. 112-133
Kates, Robert W.; Haas, Eugene J.; Amaral, Daniel J.; Olson, Robert A.; et.al.
(1973) Human impact of the Managua earthquake, Science, vol. 182, no. 7, pp.
981-990
Katz, Cindy (1994) Playing the field: Questions of fieldwork in geography, The
Professional Geographer, vol. 46, no. 1, pp. 67-72
Kawachi, Ichiro and Wamala, Sarah (eds.) (2007) Globalization and Health,
Oxford University Press: New York
Kearns, Robin A. (1993) Place and Health: towards a reformed medical
geography, Professional Geographer, vol. 45, pp. 139-47
Kearns, Robin and Collins, Damian (2010) “Health Geography”, in: Brown, T.,
McLafferty, S. and Moon, G. (eds.) A companion to health and medical
geography, Blackwell Companions to Geography, No. 8, Wiley-Blackwell:
Oxford
Kearns, Robin A. and Gesler, Wilbert M. (eds.) (1998) Putting health into
place: Landscape, Identity, & Well-being, Syracuse University Press: New
York
Kearns, Robin A. and Moon, Graham (2002) From medical to health
geography: novelty, place and theory after a decade of change, Progress in
Human Geography, vol. 26, no. 5, pp. 605-625
Kenworthy Teather, Elisabeth (1999) “Introduction: Geographies of personal
discoveries”, in: Kenworthy, T. (ed.) Embodied geographies: spaces, bodies
and rites of passage, Routledge: London
Khan, Koushambhi Basu; McDonald, Heather; Baumbusch, Jennifer L.;
Kirkham Reimer, Sheryl; Tan, Elsie; Anderson, Joan M. (2007) Taking up
postcolonial feminism in the field: Working through a method, Women's
Studies International Forum, vol. 30, no. 3, pp. 228-242
Khosravi, Shahram (2011) ‘Illegal’ Traveller: An Auto-Ethnography of
Borders, Global Ethics Series, Palgrave Macmillan: Basingstoke
Kincheloe, Joe and McLaren, Peter (2003) “Rethinking Critical Theory and
Qualitative Research”, in: Denzin, N. and Lincoln, Y. (eds.) The Landscape of
Qualitative Research: Theories and Issues, Part I of Handbook of Qualitative
Research, 2nd edition, Sage: Thousand Oaks/London/New Delhi
311
King, Russell (2002) Towards a New Map of European Migration,
International Journal of Population Geography, vol. 8, no. 2, pp. 89-106
King, Russell (2012) Geography and Migration Studies: Retrospect and
Prospect, Population, Space and Place, vol. 18, no. 1, pp. 134-153
King, Russell and Vullnetari, Julie (2010) Gender and Remittances in
Albania: Or, Why ‘Are Women Better Remitters Than Men?’ is Not the Right
Question, Working Paper 58, Sussex Centre for Migration Research: Brighton
Konseiga, Adama; Zulu, Eliya M.; Bocquier, Philippe; Muindi, Kanyiva;
Beguy, Donatien; and Yé, Yazoumé (2009) “Assessing the Effect of Mother’s
Migration on Childhood Mortality in the Informal Settlements in Nairobi”, in:
Collinson, M., Adazu, K., White, M., and Findley, S. (eds.) The Dynamics of
Migration, Health and Livelihoods. INDEPTH Network Perspectives,
Ashgate Publishing: Farnham
Kwan, Mei-Po (2004) Beyond difference: From canonical geography to hybrid
geographies, Annals of the Association of American Geographers, vol. 94, no.
4, pp. 756-763
Lancaster, Robert N. (1992) Life is Hard: Machismo, Danger, and the
Intimacy of Power in Nicaragua, University of California Press: California
Larson, Elizabeth M. (1993) Nicaraguan refugees in Costa Rica from 19801993, Yearbook: Conference of Latin Americanist Geographers, vol. 19, pp.
67-79
Lawson, Victoria (1995) The politics of difference: Examining the
quantitative/qualitative dualism in post-structuralist feminist research, The
Professional Geographer, vol. 47, no. 4, pp. 449–457
Lawson, Victoria (2007) Geographies of Care and Responsibility, Annals of
the Association of American Geographers, vol. 97, no. 1, pp. 1-11
Lawson, Victoria and Silvey, Rachel (1999) Placing the migrant, Annals of the
Association of American Geographers, vol. 89, no. 1, pp. 121-132
Lazarus, Richard S. (2006) Stress and emotion: a new synthesis, Springer
Publishing Company: New York
Lazarus, Richard S. and Folkman, Susan (1984) Stress, Appraisal, and
Coping, Springer Publishing Company: New York
Lee, Kelley and Collin, Jeff (2005) Global Change and Health, Open
University Press: Berkshire
Lefebvre, Henri (1991) The Production of Space, Blackwell: Oxford
Leifsen, Esben and Tymczuk, Alexander (2012) Care at a Distance: Ukrainian
and Ecuadorian Transnational Parenthood from Spain, Journal of Ethnic and
Migration Studies, vol. 38, no. 2, pp. 219-236
Leinaweaver, Jessaca B. (2008) Improving Oneself: Young People Getting
Ahead in the Peruvian Andes, Latin American Perspectives, vol. 35, no. 4, pp.
60-78
312
Levitt, Peggy and Glick Schiller, Nina (2004) Conceptualizing Simultaneity: A
Transnational Social Field Perspective on Society 1, International Migration
Review, vol. 38, no. 3, pp. 1002-1039
Lewis, Michael; Haviland-Jones, Jeanette M.; and Feldman Barrett, Lisa
(eds.) (2008) Handbook of Emotions, 3rd edition, The Guilford Press: New
York
Ley, David and Samuels, Marwyn S. (eds.) (2014) Humanistic Geography:
Prospects and Problems, 2nd edition (1st edition published 1978), Routledge:
Abingdon/New York
Lincoln, Yvonna S. and Guba, Egon G. (2003) “Paradigmatic Controversies,
Contradictions, and Emerging Confluences”, in: Denzin, N. and Lincoln, Y.
(eds.) The Landscape of Qualitative Research: Theories and Issues, Part I of
Handbook of Qualitative Research, 2nd edition, Sage: Thousand
Oaks/London/New Delhi
Lovell, W. George and Lutz, Christopher H. (1991/1992) The historical
demography of colonial Central America, Yearbook: Conference of Latin
Americanist Geographers, vol. 17/18, Benchmark 1990
Lugones, Maria (2007) Heterosexualism and the Colonial/Modern Gender
System, Hypatia, vol. 22, no. 1, pp. 186-209
Lupton, Deborah (1998) “Going with the flow: some central discourses in
conceptualising and articulating the embodiement of emotional states”, in:
Nettleton, S. and Watson, J. (eds.) The Body in Everyday Life, Routledge:
London
Lutz, Helma (2002) At your service madam! The globalization of domestic
service, Feminist Review, vol. 70, pp. 89-104
MacPherson, Douglas W. and Gushulak, Brian D. (2001) Human mobility and
population health: new approaches in a globalizing world, Perspectives in
Biology and Medicine, vol. 44, no. 3, pp. 390-401
Malkii, Liisa (1995) Purity and Exile: Violence, Memory, and National
Cosmology among Hutu Refugees in Tanzania, University of Chicago Press:
Chicago
Marchand, Marianne H. (2009) The future of Gender and Development after
9/11: insights from postcolonial feminisms and transnationalism, Third
World Quarterly, vol. 30, no. 5, pp. 921-936
Martínez Franzoni, Juliana and Voorend, Koen (2011) Who Cares in
Nicaragua? A Care Regime in an Exclusionary Social Policy Context,
Development and Change, vol. 42, no. 4, pp. 995-1022
Marquette, Catherine M. (2006) Nicaraguan Migrants in Costa Rica,
Población y Salud en Mesoamérica, vol. 4, no. 1, University of Costa Rica
Massey, Doreen (2005) For Space, Sage: London
Massey, Doreen (1994) Space, Place, and Gender, University of Minnesota
Press: Minnesota
313
Massey, Douglas S. and Sana, Mariano (2003) Patterns of US migration from
Mexico, the Caribbean, and Central America, Migraciones Internacionales,
vol. 2, no. 2, pp. 5-39
Mayer, Jonathan D. (2010) “Medical geography”, in: Brown, T., McLafferty,
S., and Moon, G. (eds.) A companion to health and medical geography,
Blackwell Companions to Geography, No. 8, Wiley-Blackwell: Oxford
Mawani, Farah N. and Gilmour, Heather (2010) Validation of self-rated
mental health, Statistics Canada, Health Reports, vol. 21, no. 3, pp. 61-75
McCracken, K. (2009) Epidemiological Transition,
Encyclopedia of Human Geography, pp. 571-579
International
McDowell, Linda (1999) Gender, identity and place: Understanding Feminist
Geographies, University of Minnesota Press: Minnesota
McDowell, Linda; Batnitzky, Adina; and Dyer, Sarah (2009) Precarious Work
and Economic Migration: Emerging Immigrant Divisions of Labour in Greater
London’s Service Sector, International Journal of Urban and Regional
Research, vol. 33, no. 1, pp. 3-25
McGarry, Julie (2010) Exploring the effect of conducting sensitive research,
Nurse Researcher, vol. 18, no. 1, pp.8-14
McKay, Deirdre (2007) ‘Sending Dollars Shows Feeling’ – Emotions and
Economies in Filipino Migration, Mobilities, vol. 2, no. 2, pp. 175-194
McKay, Laura; Macintyre, Sally; and Ellaway, Anne (2003) Migration and
Health: A Review of the International Literature, Medical Research Council,
Social and Public Health Sciences Unit, Occasional Paper no. 2, January 2003,
University of Glasgow: Glasgow
McKay, Sandra Lee and Wong, Sau-ling Cynthia (eds.) (2000) New
immigrants in the United States, Readings for second language educators,
Cambridge University Press: Cambridge
McKenzie, Sean and Menjívar, Cecilia (2011) The meanings of migration,
remittances and gifts: views of Honduran women who stay, Global Networks,
vol. 11, no. 1, pp. 63–81
McKendrick, John H. (1999) Multi-Method Research: An Introduction to its
Application in Population Geography, Professional Geographer, vol. 51, no.1,
pp. 50-59
Mendez, Jennifer Bickham (2005) From the revolution to the maquiladoras.
Gender, Labor, and Globalization in Nicaragua, Duke University Press:
Durham
Menjívar, Cecilia (2012) Transnational Parenting and Immigration Law:
Central Americans in the United States, Journal of Ethnic and Migration
Studies, vol. 38, no. 2, pp. 301-322
Mirza, Heidi S. (2009) Plotting a history: Black and postcolonial feminism in
new times, Race, Ethnicity and Education, vol. 12, no. 1, pp. 1-10
314
Montes, Veronica (2013) The Role of Emotions in the Construction of
Masculinity: Guatemalan Migrant Men, Transnational Migration, and Family
Relations, GENDER & SOCIETY, vol. 27, no. 4, pp. 469-490
Moon, Graham (2009) Health Geography, International Encyclopedia of
Human Geography, pp. 35-45
Morales, Abelardo and Castro, Carlos (2002) Redes Transfronterizas.
Sociedad, empleo y migración entre Nicaragua y Costa Rica [Transborder
networks. Society, employment and migration between Nicaragua and Costa
Rica], Facultad Latinoamericana de Ciencias Sociales (FLACSO) [Latin
American Faculty of Social Sciences], FLACSO: San José
Morales, Abelardo and Castro, Carlos (2006) Migración, empleo y pobreza
[Migration, employment and poverty], Facultad Latinoamericana de Ciencias
Sociales (FLACSO) [Latin American Faculty of Social Sciences], FLACSO: San
José
Morales, Abelardo; Acuña, Guillermo; and Wing-Ching, Karina Li (2009)
Migración y salud en zonas fronterizas: Nicaragua y Costa Rica [Migration
and health in border zones: Nicaragua and Costa Rica], CELADE – Population
Division of CEPAL, UNFPA/United Nations: Santiago de Chile
Morgan, David L. (2007) Paradigms Lost and Pragmatism Regained:
Methodological Implications of Combining Qualitative and Quantitative
Methods, Journal of Mixed Methods Research, vol. 1, no. 1, pp. 48-76
Moss, N; Stone, M.C; and Smith, J.B. (1992) Child health outcomes among
Central-American refugees and immigrants in Belize, Social Science &
Medicine, vol. 34, no. 2, pp. 161-167
Muiser, Jorine; del Rocío Sáenz, María; and Bermúdez, Juan Luis (2011)
Sistema de salud de Nicaragua [Nicaragua’s Health System], Salud Pública de
México, vol. 53, supl. 2, S233-S242
Mulinari, Diana (1995) Motherwork and Politics in Revolutionary
Nicaragua:”Huellas de Dolor y Esperanza”, Bokbox Förlag: Lund
Nettleton, Sarah and Gustafsson, Ulla (eds.) (2002) The Sociology of Health
and Illness Reader, Polity Press: Cambridge
Nettleton, Sarah and Watson, Jonathan (eds.) (1998) The Body in Everyday
Life, Routledge: London
Newland, Carlos (1994) The Estado Docente and Its Expansion: Spanish
American Elementary Education, 1900-1950, Journal of Latin American
Studies, vol. 26, no. 2, pp. 449-467
Newman, David (2003) On borders and power: A theoretical framework,
Journal of Borderlands Studies, vol. 18, no. 1, pp. 13-25
Nicholson, Michele (2006) Without Their Children: Rethinking Motherhood
among Transnational Migrant Women, Social Text 88, vol. 24, no. 3, pp. 1333
315
Obando Medina, Claudia (2011) When no-one notices… Studies on suicidal
expression among young people in Nicaragua, Dissertation, Umeå
University, Department of Clinical Sciences, Division of Psychiatry
Olwig, Karen Fog and Sørensen, Ninna Nyberg (2002) “Mobile livelihoods:
Making a living in the world”, in: Sørensen, N. and Olwig, K. (eds.) Work and
Migration: Life and livelihoods in a globalizing world, Routledge: London
Orb, Angelica; Eisenhauer, Laurel; and Wynaden, Dianne (2001) Ethics in
Qualitative Research, Journal of Nursing Scholarship, vol. 33, no. 1, pp. 9396
Orraca Romano, Pedro P. and Corona Villavicencio, Francisco de J. (2014)
Risk of Death and Aggressions Encountered while Illegally Crossing the U.S.Mexico Border, Migraciones Internacionales, vol. 7, no. 3, pp. 9-41
Otto, Ton and Bubandt, Nils (eds.) (2010) Experiments in Holism: Theory
and Practice in Contemporary Anthropology, Wiley Blackwell: West Sussex
Paavilainen, Eija; Lepistö, Sari; and Flinck, Aune (2014) Ethical issues in
family violence research in healthcare settings, Nursing Ethics, vol. 21, no. 1,
pp. 43-52
Paerregaard, Karsten (2008) Peruvians dispersed. A Global Ethnography of
Migration, Lexington Books: Lanham/Plymouth
PAHO (2009) Health Systems Profile in Nicaragua: Monitoring and
Analyzing Health Systems Change/Reform, 3rd edition, Pan American Health
Organization (PAHO): Washington
Paradies, Yin (2006) A systematic review of empirical research on selfreported racism and health, International Journal of Epidemiology, vol. 35,
pp. 888-901
Parr, Hester (2004) Medical geography: critical medical and health
geography?, Progress in Human Geography, vol. 28, no. 2, pp. 246-257
Parr, Hester (2005) “Emotional Geographies”, in: Cloke, P., Crang, P. and
Goodwin, M. (eds.) Introducing Human Geography, Arnold: London
Parr, Hester and Butler, Ruth (1999) “New geographies of illness, impairment
and disability”, in: Butler, R. and Hester, P. (eds.) Mind and body spaces:
geographies of illness, impairment and disability, Routledge: London
Parreñas, Rhacel S. (2000) Migrant Filipina Domestic Workers and the
International Division of Reproductive Labor, Gender and Society, vol. 14, no.
4, pp. 560-580
Parreñas, Rhacel S. (2001) Mothering from a Distance: Emotions, Gender and
Inter-Generational Relations in Filipino Transnational Families, Feminist
Studies, vol. 27, no. 2, pp. 361-390
Parreñas, Rhacel S. (2002) “The care crisis in the Philippines: children and
transnational families in the new global economy”, in: Ehrenreich, B. and
316
Hochschild, A. (eds.) Global Woman: Nannies, Maids and Sex Workers in the
New Economy, Metropolitan Books: New York
Parreñas, Rhacel S. (2005) Long Distance Intimacy: Class, Gender and
Intergenerational Relations Between Mothers and Children in Filipino
Transnational Families, Global Networks, vol. 5, no. 4, pp. 317-336
Parreñas, Rhacel S. (2008) Transnational fathering: gendered conflicts,
distant disciplining and emotional gaps, Journal of Ethnic and Migration
Studies, vol. 34, no. 7, pp. 1057-72
Parrott, Gerrod W. (ed.) (2001) Emotions in social psychology: Essential
readings, Psychology Press: New York/London
Pastor, Robert A. (1987) Condemned to repetition: the United States and
Nicaragua, Princeton University Press: Princeton, New Jersey
Pearce, Jamie (2003) Emerging new research in the geography of health and
impairment, Health & Place, vol. 9, pp. 107-108
Pearce, Jamie and Dorling, Danny (2009) Tackling global health inequalities:
closing the health gap in a generation, Environment and Planning A, vol. 41,
no. 1, pp. 1-6
Pennebaker, James W. (1995) “Emotion, Disclosure, and Health: An
Overview”, in: Pennebaker, J. (ed.) Emotion, Disclosure, and Health,
American Psychological Association: Washington
Pennebaker, James W. and Seagal, Janel D. (1999), Forming a story: The
health benefits of narrative, Journal of Clinical Psychology, vol. 55, no. 10,
pp. 1243-1254
Peña, Rodolfo; Liljestrand, Jerker; Zelaya, Elmer; and Persson, Lars-Åke
(1999) Fertility and infant mortality trends in Nicaragua 1964-1993. The role
of women’s education, Journal of Epidemiology and Community Health, vol.
53, pp. 132-137
Peña, Rodolfo; Pérez, Wilton; Meléndez, Marlon; and Källestål, Carina (2005)
Reporte de Línea de Base del Sistema de Vigilancia en Demografía y Salud,
León, Nicaragua, 2002 [Report from the Health and Demographic
Surveillance System, León, Nicaragua, 2002], CIDS [Centre for Demographic
and Health Research] and Umeå University, Unpublished Report
Peña, Rodolfo; Pérez, Wilton; Melendez, Marlon; Källestål, Carina; and
Persson, Lars-Åke (2008) The Nicaraguan Health and Demographic
Surveillance Site, HDSS-León: A platform for public health research,
Scandinavian Journal of Public Health, vol. 38, no. 3, pp. 318-325
Pendall, Rolf; Theodos, Brett, and Franks, Kaitlin (2012) Vulnerable people,
precarious housing and regional resilience: an exploratory analysis, Housing
Policy Debate, vol. 22, no. 2, pp. 271-296
Pérez, Wilton (2012) Millennium Development Goals in Nicaragua.
Analysing progress, social inequalities, and community actions,
317
Dissertation, Uppsala University, Department of Women's and Children's
Health, International Maternal and Child Health (IMCH)
Pérez-Arias, Enrique (1997) Mellan det förflutna och framtiden: Den
sandinistiska revolutionen i Nicaragua, Lund Monographs in Social
Anthropology 3, Sociologiska institutionen, Lunds Universitet
Pew Hispanic Center (2013) Hispanics of Nicaraguan Origin in the United
States, 2011, Statistical Profile, June 19 2013, available online at:
http://www.pewhispanic.org/files/2013/06/NicaraguanFactsheet.pdf
Phillips, David R. and Rosenberg, Mark W. (2000) Researching the geography
of health and health care: Connecting with the Third World, GeoJournal, vol.
50, pp. 369-378
Phillips, David R. and Verhasselt, Yola (eds.) (1994) Health and Development,
Routledge: London
Portes, Alejandro (2009) Migration and development: reconciling opposite
views, Ethnic and Racial Studies, vol. 32, no. 1, pp. 5-22
Portes, Alejandro; Guarnizo, Luis E.; and Landolt, Patricia (1999) The study
of transnationalism: pitfalls and promise of an emergent research field, Ethnic
and Racial Studies, vol. 22, no. 2, pp. 217-237
Pozzoli D., and Ranzani M. (2009) Participation and Sector Selection in
Nicaragua, Aarhus School of Business, Department of Economics, Working
Paper 09-8
Potter, Robert B.; Binns, Tony; Elliott, Jennifer A.; and Smith, David (2008)
Geographies of Development, 3rd edition, Pearson Prentice Hall: Harlow
Pribilsky, Jason (2004) ‘Aprendemos a convivir’: conjugal relations, coparenting, and family life among Ecuadorian transnational migrants in New
York City and the Ecuadorian Andes, Global Networks, vol. 4, no. 3, pp. 313334
Raghuram, Parvati (2009) Which Migration, What Development? Unsettling
the Edifice of Migration and Development, Population, Space and Place, vol.
15, no. 1, pp. 103-117
Reay, Diane (2005) Beyond Consciousness?: The Psychic Landscape of Social
Class, Sociology, volume 39, no. 5, pp. 911–928
Regeringskansliet (March 17 2008) Regeringens skrivelse [Government Bill]
2007/08:89: Globala utmaningar – vårt ansvar. Skrivelse om Sveriges
politik för global utveckling [Global challenges – our responsibility. Bill on
Sweden’s policy for global development], Regeringskansliet [Government
Offices of Sweden], Elanders: Stockholm. Available online at:
http://www.regeringen.se/content/1/c6/10/10/82/03480187.pdf
Regeringskansliet/Utrikesdepartementet (August 27 2008) Ett fokuserat
bilateralt utvecklingssamarbete [A focused bilateral development cooperation], Regeringskansliet [Government Offices of Sweden],
318
Utrikesdepartementet [Ministry of Foreign Affairs], available online at:
http://www.regeringen.se/content/1/c6/10/11/86/2c37d9ae.pdf
Revels, Craig S. (2000) Coffee in Nicaragua: Introduction and Expansion in
the Nineteenth Century, Yearbook: Conference of Latin Americanist
Geographers, vol. 26, pp. 17-28
Riessman, Catherine Kohler (2008) Narrative methods for the human
sciences, Sage: London
Rigg, Jonathan (2007) Moving Lives: Migration and Livelihoods in Lao PDR,
Population, Space and Place, vol. 13, pp. 163-178
Roberts, Brian (2002) Biographical research, Open University Press:
Buckingham
Robertson, Roland (1995) “Glocalization: time-space and homogeneityheterogeneity”, in: Featherstone, M., Lash, S. and Robertson, R. (eds.) Global
modernities, Sage: London
Robinson, Vaughan (ed.) (1996) Geography and Migration, Edward Elgar
Publishing Company: Cheltenham/Brookfield
Robinson, William I. (2001) Transnational processes, development studies
and changing social hierarchies in the world system: a Central American case
study, Third World Quarterly, vol. 22, no. 4, pp. 529–563
Robinson, William I. and Norsworthy, Kent (1985) Elections and U.S.
Intervention in Nicaragua, Latin American Perspectives, vol. 12, no. 2, pp. 83110
Rosenberg, Mark W. and Wilson, Kathleen (2005) Remaking Medical
Geography, Territoris, vol. 5, pp. 17-32
Rosenberg, Mark W. (1998) Medical or Health Geography? Populations,
Peoples and Places, Research Review 5, International Journal of Population
Geography, 4, pp. 211-226
Rosenthal, Gabriele (2003) The healing effects of storytelling: On the
conditions of curative storytelling in the context of research and counselling,
Qualitative Inquiry, vol. 9, no. 6, pp. 915-933
Ruger, Jennifer P. (2003) Health and development, Lancet, vol. 362, p. 678
Ruiz Marrujo, Olivia T. (2009) “Women, Migration, and Sexual Violence:
Lessons from Mexico’s Borders”, in: Staudt, K., Payan, T., and Kruszewski, A.
(eds.) Human rights along the U.S.-Mexico border: gendered violence and
insecurity, University of Arizona Press: Arizona
Salazar Torres, Mariano Virgilio (2011) Intimate Partner Violence in
Nicaragua: Studies on ending abuse, child growth, and contraception,
Dissertation, Umeå University, Department of Public Health and Clinical
Medicine, Epidemiology and Global Health
Salazar Torres, Mariano Virgilio; Goicolea, Isabel; Edin, Kerstin; and Öhman,
Ann (2012) ‘Expanding your mind’: the process of constructing gender-
319
equitable masculinities in young Nicaraguan men participating in
reproductive health or gender training programs, Global Health Action, vol. 5
Sale, Joanna EM; Lynne H. Lohfeld; and Kevin Brazil (2002) Revisiting the
quantitative-qualitative debate: Implications for mixed-methods research,
Quality and Quantity, vol. 36, no.1, pp. 43-53
Sánchez-Carretero, Christina (2005) Motherhood from Afar: Channels of
Communication among Dominican Women in Madrid, Migration: a
European journal of international migration and ethnic relations, Special
issue: from emigration to immigration to transmigration? New research
perspectives on Spain, 43/44/45, Berliner Instituts für Vergleichende
Sozialforschung
Sandiford, Peter; Morales, Patricia; Gorter, Anna; Coyle, Edward; Davey
Smith, George (1991) Why do child mortality rates fall? An analysis of the
Nicaraguan experience, American Journal of Public Health, vol. 81, no. 1, pp.
30-37
Sandoval-García, Carlos (2004) Threatening Others: Nicaraguans and the
formation of national identities in Costa Rica, Center for International
Studies, Ohio University: Ohio
Sangmpam, S N (1995) The overpoliticised state and international politics:
Nicaragua, Haiti, Cambodia and Togo, Third World Quarterly, vol. 16, no. 4,
pp. 619-642
Sapkota, Sanjeeb; Kohl III, Harold; Gilchrist, Julie; McAuliffe, Jay; et al.
(2006) Unauthorized Border Crossings and Migrant Deaths: Arizona, New
Mexico, and El Paso, Texas, 2002-2003, American Journal of Public Health,
vol. 96, no. 7, pp. 1282-1287
Schaerström, Anders; Rämgård, Margareta; and Löfman, Owe (2011) Hälsans
och ohälsans landskap: Från medicinsk geografi till hälsogeografi,
[Landscapes of health and disease: From medical geography to health
geography], Studentlitteratur: Lund
Schmalzbauer, Leah (2004) Searching for wages and mothering from afar: the
case of Honduran transnational families, Journal of Marriage and the
Family, vol. 66, pp. 1317–1331
Schmalzbauer, Leah (2008) Family divided: the class formation of Honduran
transnational families, Global Networks, vol. 8, no. 3, pp. 329-346
Schmalzbauer, Leah (2010) Disruptions, dislocations, and inequalities:
transnational Latino/a families surviving the global economy, Symposium:
Globalization, Families, and the State, North Carolina Law Review, vol. 88,
no. 5, pp. 1857-1880
Schmalzbauer, Leah (2013) Temporary and transnational: gender and
emotion in the lives of Mexican guest worker fathers, Ethnic and Racial
Studies, ahead-of-print (2013)
Schwandt, Thomas A. (2003) “Three Epistemological Stances for Qualitative
Inquiry: Interpretivism, Hermeneutics, and Social Constructionism”, in:
320
Denzin, N. and Lincoln, Y. (eds.) The Landscape of Qualitative Research:
Theories and Issues, Part I of Handbook of Qualitative Research, 2nd edition,
Sage: Thousand Oaks/London/New Delhi
Sen, Amartya (2000) Development as Freedom: Human Capability and
Global Need, Anchor Books: New York
Seeman, Teresa E. (1996) Social Ties and Health: The Benefits of Social
Integration, AEP, vol. 6, no. 5, pp. 442-451
Sequeira, Magda; Espinoza, Henry; Amador, Juan J.; Domingo, Gonzalo;
Quintanilla, Margarita; and de los Santos, Tala (2011) The Nicaragua Health
System: An overview of critical challenges and opportunities, Program for
Appropriate Technology in Health (PATH): Seattle/Washington
Shorter, Edward (2005) “The history of the biopsychosocial approach in
medicine: before and after Engel”, in: White, P. (ed.) Biopsychosocial
medicine: an integrated approach to understanding illness, Oxford
University Press: Oxford
Sida (2008) Sida Country Report 2007: Nicaragua, Embassy of Sweden in
Nicaragua, Sida: Stockholm
Silver, Alexis (2011) Families Across Borders: The Emotional Impacts of
Migration on Origin Families, International Migration, vol. 52, no. 3, pp. 194220
Silvey, Rachel (2006) Geographies of gender and Migration: Spatializing
Social Difference, International Migration Review, vol. 40, no. 1, pp. 64-81
Siriwardhana, Chesmal; Adikari, Anushka; Jayaweera, Kaushalya; and
Sumathipala, Athula (2013) Ethical challenges in mental health research
among internally displaced people: ethical theory and research
implementation, BMC Medical Ethics 2013, vol. 14, no. 13
Skeldon, Ronald (1990) Population Mobility in Developing Countries: A
Reinterpretation, Belhaven: London
Skeldon, Ronald (1995) The challenge facing migration research: a case for
greater awareness, Opinion and Comment, Progress in Human Geography,
vol. 19, no. 1, pp. 91-96
Slack, Jeremy and Whiteford, Scott (2011) Violence and Migration on the
Arizona-Sonora Border, Society for Applied Anthropology, vol. 70, no. 1, pp.
11-21
Smith, Mick; Davidson, Joyce; Cameron, Laura; and Bondi, Liz (eds.) (2009)
Emotion, Place and Culture, Ashgate: Farnham
Smith, Susan J. and Easterlow, Donna (2005) The Strange Geography of
Health Inequalities, Transactions of the Institute of British Geographers, vol.
30, no. 2, pp. 173-190
Soares, Rodrigo R. (2009) Life expectancy and welfare in Latin America and
the Caribbean, Health Economics, vol. 18, supplement 1, pp. S37–S54
321
Spalding, Rose J. (1994) Capitalists and Revolution in Nicaragua: opposition
and accommodation 1979-1993, University of North Carolina Press
Staeheli, Lynn A. and Lawson, Victoria A. (1994) A Discusion of ‘Women in
the Field’: The Politics of Feminist Fieldwork, The Professional Geographer,
vol. 46, no. 1, pp. 96-102
Stake, Robert E. (2003) “Case Studies”, in: Denzin, N. and Lincoln, Y. (eds.)
Strategies of Qualitative Inquiry, Part II of Handbook of Qualitative
Research, 2nd edition, Sage: Thousand Oaks/London/New Delhi
Standing, Guy (2014) The Precariat: The new dangerous class, 2nd edition
(first published 2011), Bloomsbury: London/New York
Staten, Clifford L. (2010) The history of Nicaragua, The Greenwood Histories
of the Modern Nations Series, ABC-CLIO, LLC: Santa Barbara, California
Steel, Griet; Winters, Nanneke; and Sosa, Carlos (2011) Mobility, translocal
development and the shaping of development corridors in (semi-)rural
Nicaragua, International Development Planning Review, vol. 33, no. 4
Stewart, Miriam; Makwarimba, Edward; Barnfather, Alison; Letourneau,
Nicole; and Neufeld, Anne (2008) Researching reducing health disparities:
Mixed-methods approaches, Social Science & Medicine, vol. 66, no. 6, pp.
1406-1417
Stjernström, Olof (1998) Flytta nära, långt bort: De sociala nätverkens
betydelse för val av bostadsort [Move closer, far away: The importance of
social networks for place-of-residence decisions], Dissertation, GERUM
Kulturgeografi 1998:1
Suárez‐Orozco, Cerola; Todorova, Irina L. G.; and Louie, Josephine (2002)
Making Up For Lost Time: The Experience of Separation and Reunification
Among Immigrant Families, Family Process, vol. 41, no. 4, pp. 625-643
Sui, Daneil and DeLyser, Dydia (2012) Crossing the qualitative-quantitative
chasm I: Hybrid geographies, the spatial turn, and volunteered geographic
information (VGI), Progress in Human Geography, vol. 36, no. 1, pp. 111-124
Svaŝek, Maruška (2008) Who Cares? Families and Feelings in Movement,
Journal of Intercultural Studies, vol. 29, no.3, pp. 213-230
Tan, Brian and Yeoh, Brenda (2011) “Translocal Family Relations amongst the
Lahu in Northern Thailand”, in: Brickell, K. and Datta, A. (eds.) Translocal
Geographies: Spaces, Places, Connections, Ashgate: Farnham
Tarlov, Alvin R. (2000) Coburn’s thesis: plausible, but we need more evidence
and better measures, Social Science & Medicine, vol. 51, no. 7, pp. 993-995
Teddlie, Charles and Tashakkori, Abbas (2009) Foundations of Mixed
Methods Research: Integrating Quantitative and Qualitative Approaches in
the Social and Behavioural Sciences, Sage: Thousands Oaks/London
Tedlock, Barbara (2003) “Ethnography and Ethnographic Representation”,
in: Denzin, N. and Lincoln, Y. (eds.) Strategies of Qualitative Inquiry, Part II
322
of Handbook of Qualitative Research, 2nd edition, Sage: Thousand
Oaks/London/New Delhi
Thieme, Susan (2008) Sustaining Livelihoods in Multi-local Settings: Possible
Theoretical Linkages Between Transnational Migration and Livelihood
Studies, Mobilities, vol. 3, no. 1, pp. 51-71
Thoits, Peggy A. (1995) Stress, Coping, and Social Support Processes: Where
Are We? What next?, Journal of Health and Social Behaviour, Extra Issue:
Forty Years of Medical Sociology: The State of the Art and Directions for the
Future, vol. 35, pp. 53-79
Thoits, Peggy A. (2010) Stress and Health: Major Findings and Policy
Implications, Journal of Health and Social Behaviour, Extra Issue: What Do
We Know? Key Findings from 50 Years of Medical Sociology, vol. 51, pp. S41S53
Thomas, Felicity and Gideon, Jasmine (eds.) (2013) Migration, health and
inequality, Zed Books: London/New York
Thomas, Felicity and Gideon, Jasmine (2013) “Introduction”, in: Thomas, F.
and Gideon, J. (eds.) Migration, health and inequality, Zed Books:
London/New York
Tollefsen Altamirano, Aina (2000) Seasons of Migrations to the North. A
Study of Biographies and Narrative Identities in US-Mexican and SwedishChilean Return Movements, Dissertation, GERUM Kulturgeografi 2000:3
Tollefsen, Aina and Lindgren, Urban (2006) Transnational citizens or
circulating semi-proletarians? A study of migration circulation between
Sweden and Asia, Latin America and Africa between 1968 and 2002,
Population, Space and Place, vol. 12, no. 6, pp. 517-527
Tompa, Emile; Scott-Marshall, Heather; Dolinschi, Roman; Trevithick, Scott;
and Bhattacharyya, Sudipa (2007) Precarious employment experiences and
their health consequences: Towards a theoretical framework, Work, vol. 28,
pp. 209-224
Torres Rivas, Edelberto (1993) History and society in Central America,
English edition, Institute of Latin American Studies, University of Texas
Press: Austin
Toyota, Mika.; Yeoh, Brenda S.A.; and Nguyen, Liem (2007) Editorial
introduction: Bringing the ‘Left Behind’ Back into View in Asia: A Framework
for Understanding The ‘Migration-Left Behind Nexus’, Population, Space and
Place, vol. 13, no. 3, pp. 157-161
Trudgill, Stephen and Roy, André (eds.) (2014) Contemporary Meanings in
Physical Geography: From what to why?, Routledge: Abingdon/New York
Turner, Bryan (2004) The New Medical Sociology: Social Forms of Health
and Illness, W.W. Norton & Company: New York
Turner, Jonathan H. (2007) Human Emotions: A sociological theory,
Routledge: New York
323
UN (2013) The Millenium Development Report 2013, the United Nations
(UN): New York
UN/ECLAC (1999) Nicaragua: Assessment of the damage caused by
Hurricane Mitch, 1998. Implications for economic and social development
and for the environment, United Nations (UN), Economic Commission for
Latin America and the Caribeean (ECLAC), 19 April 1999
UN DESA (2013) Cross-national comparisons of internal migration: An
update on global patterns and trends, United Nations Department of
Economic and Social Affairs (UN DESA), Population Division, Technical
Paper No. 2013/1, United Nations: New York
UNDP (1990) Human Development Report 1990, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (1991) Human Development Report 1991, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (1992) Human Development Report 1992, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (1996) Human Development Report 1996, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (1997) Human Development Report 1997, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (1998) Human Development Report 1998, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (1999) Human Development Report 1999, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (2000) Human Development Report 2000, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (2001) Human Development Report 2000, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (2002) Human Development Report Nicaragua 2002. Conditions of
hope, the United Nations Development Programme (UNDP): New York
UNDP (2003) Human Development Report 2003, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (2005) Human Development Report 2005, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (2009) Human Development Report 2009, Overcoming barriers:
Human mobility and development, the United Nations Development
Programme (UNDP): New York
UNDP (2010) Human Development Report 2010, the United Nations
Development Programme (UNDP), Oxford University Press: New York
324
UNDP (2011) Human Development Report 2011, the United Nations
Development Programme (UNDP), Oxford University Press: New York
UNDP (2013) Human Development Report 2013, The Rise of the South:
Human Progress in a Diverse World, the United Nations Development
Programme (UNDP): New York
UNDP (2014) Human Development Report 2014, Sustaining Human
Progress: Reducing Vulnerabilities and Building Resilience, the United
Nations Development Programme (UNDP): New York
Urry, John (2000) Mobile sociology, British Journal of Sociology, vol. 51, no.
1, pp. 185-203
Urry, John (2007) Mobilities, Polity Press: Cambridge
Valladares Cardoza, Elliette (2005) Partner Violence during Pregnancy:
Psychosocial Factors and Child Outcomes in Nicaragua, Dissertation, Umeå
University, Epidemiology and Public Health Sciences, Department of Public
Health and Clinical Medicine
Van Liempt, Ilse and Bilger, Veronika (2009) The ethics of migration
research methodology: dealing with vulnerable immigrants, Sussex
Academic Press: Eastbourne
Vargas, Oscar-René (2006) Nicaragua 2015: Los Objetivos de Desarrollo del
Milenio [Nicaragua 2015: The Millenium Development Goals], Centro de
Estudios de la Realidad Nacional (CEREN): Nicaragua
Veenstra, Gerry (2013) Race, gender, class, sexuality (RGCS) and
hypertension, Social Science & Medicine, vol. 89, pp. 16-24
Vertovec, Steven (2009) Transnationalism, Routledge: London
Vitetta, L.; Anton, B., Cortizo, F.; and Sali, A. (2005) Mind-Body Medicine:
Stress and Its Impacts on Overall Health and Longevity, Annals of the New
York Academy of Sciences, vol. 1057, no. 1, pp. 492-505
Vivas Vivachica, Elgin Antonio (2007) Migración interna en Nicaragua:
descripción actualizada e implicancias de política, con énfasis en el flujo
rural-urbano [Internal migration in Nicaragua: updated description and
political implications, with focus on rural-urban movements], Centro
Latinoamericano y Caribeño de Demografía (CELADE) -División de Población
de la CEPAL [CEPAL’s population division], UNFPA: Santiago de Chile, see:
http://www.cepal.org/publicaciones/xml/3/32073/lcl2839-P.pdf
Wainright, David (ed.) (2008) A Sociology of Health, Sage: London
Walker, Thomas W. and Wade, Christine J. (2009) Understanding Central
America: Global forces, Rebellion, and Change, 5th edition, Westview Press:
Boulder, Colorado
Walker, Thomas W. and Wade, Christine J. (2011) Nicaragua: Living in the
shadow of the eagle, 5th edition, Westview Press: Boulder, Colorado
325
Waters, Johanna L. (2010) Becoming a Father, Missing a Wife: Chinese
Transnational Families and the Male Experience of Lone Parenting in Canada,
Population, Space and Place, vol. 16, no. 1, pp. 63-74
Weiss, Anja (2005) The Transnationalization of Social Inequality:
Conceptualizing Social Positions on a World Scale, Current Sociology, vol. 53,
no. 4, pp. 707-728
Weiss, Gregory L. and Lonnquist, Lynne E. (2000) The Sociology of Health,
Healing, and Illness, 3rd edition, Prentice Hall: New Jersey
Weisskoff, Richard (1994) Forty-One Years of Structural Continuity and Social
Change in Nicaragua, 1950-1991, The Journal of Developing Areas, vol. 28,
no. 3, pp. 379-392
White, Peter (ed.) (2005) Biopsychosocial medicine: an integrated approach
to understanding illness, Oxford University Press: Oxford
WHO (2006) Constitution of the World Health Organization, the World
Health Organization (WHO): Geneva
Wilding, Raelene (2006) Virtual Intimacies? Families Communicating across
Transnational Contexts, Global Networks, vol. 6, no. 2, pp. 125-42
Wilkinson, Iain (2005) Suffering: A Sociological Introduction, Polity Press:
Cambridge
Wilkinson, Richard (1996) Unhealthy Societies: The Affliction of Inequality,
Routledge: London
Wilkinson, Richard (2000) Deeper than “neoliberalism”: a reply to David
Coburn, Social Science & Medicine, vol. 51, no. 7, pp. 997-1000
Wilkinson, Richard and Pickett, Kate (2009) The Spirit Level: Why Equality
is better for everyone, Penguin Books: London/New York
Williams, Simon J. and Bendelow, Gillian (1996) “Emotions, health and
illness: the ‘missing link’ in medical sociology?”, in: James, V. and Gabe, J.
(eds.) Health and the sociology of emotions, Blackwell Publishers: Oxford
Williams, David R.; Neighbors, Harold W.; and Jackson, James S. (2003)
Racial/Ethnic Discrimination and Health: Findings From Community
Studies, American Journal of Public Health, vol. 93, no. 2, pp. 200-208
Winters, Nanneke (2014) Responsibility, Mobility, and Power: Translocal
Carework Negotiations of Nicaraguan Families, International Migration
Review, vol. 48, no. 2, pp. 415-441
Wolfe, Justin (2004) Those that live by the work of their hands: Labour,
ethnicity and nation-state formation in Nicaragua, 1850-1900, Journal of
Latin American Studies, vol. 36, pp. 57-83
Wolkowitz, Carol (2006) Bodies at work, Sage: London
326
Woodward, R. L. (1985) “Central America from Independence to c. 1870”, in:
Bethell, L. (ed.) The Cambridge History of Latin America, Volume III,
Cambridge University Press: Cambridge
Yeates, Nicola (2012) Global care chains: a state-of-the-art review and future
directions in care transnationalization research, Global Networks, vol. 12, no.
2, pp. 135-154
Yeoh, Brenda S.; Graham, Elspeth; and Boyle, Peter (2002) Migrations and
Family Relations in the Asia Pacific Region, Asian and Pacific Migration
Journal, vol. 11, no. 1, pp. 1-12
Yeoh Brenda S.; Huang, S.; and Lam, T. (2005) Transnationalizing the ‘Asian’
Family: Imaginaries, Intimacies and Strategic Intents, Global Networks, vol.
5, no. 4, pp. 307-315
Yuval-Davis, Nira (1997) Women, Citizenship and Difference, Feminist
Review, no. 57, pp. 4-27
Yuval-Davis, Nira (2006) Intersectionality and Feminist Politics, European
Journal of Women’s Studies, Special Issue on Intersectionality, vol. 13, no. 3,
pp. 193–209
Yuval-Davis, Nira (2007) Intersectionality, citizenship and contemporary
politics of belonging, CRISPP, Special Issue on Contesting Citizenship, vol. 10,
no. 4, pp. 561-574
Yuval-Davis, Nira and Stoetzler, Marcel (2002) Imagined Border and
Boundaries: A Gendered Gaze, European Journal of Women's Studies, vol. 9,
no. 3, pp. 329-344
Zelaya Blandón, Elmer (1999) Adolescent pregnancies in Nicaragua: the
importance of education, Dissertation, Umeå University, Epidemiology,
Department of Public Health and Clinical Medicine
Zelaya Blandón, Elmer, Peña, Rodolfo, Betancourth, Santos, Orozco, Maria
Teresa, Meléndez, Marlon (2008) Actualización de Línea de Base. Segundo
Reporte del Sistema de Vigilancia Demográfica y de Salud de los Municipios
San Juan de Cinco Pinos, Santo Tomas, San Francisco y San Pedro del Norte.
[Actualization of the baseline. Second report from the Health and
Demographic Surveillance System in the municipalities San Juan de Cinco
Pinos, Santo Tomas, San Francisco and San Pedro del Norte], CIDS [Centre
for Health and Demographic Research] and APRODESE, Unpublished Report
Zentgraf, Kristine, M. and Chinchilla, Norma Stoltz (2012) Transnational
Family Separation: A Framework for Analysis, Journal of Ethnic and
Migration Studies, vol. 38, no. 2, pp. 345-366
Zimmerman, Cathy; Kiss, Ligia; and Hossain, Mazeda (2011) Migration and
Health: A Framework for 21st Century Policy-Making, Policy Forum, PLoS
Medicine, vol. 8, no. 5:e.1001034
327
Zuvekas, Clarence (2000) The dynamics of sectoral growth in Central
America: Recent trends and prospects for 2020, Working Paper #2, Institut
für Iberoamerika-Kunde 2000: Hamburg
Åkerlund, Ulrika (2013) The Best of Both Worlds: Aspirations, Drivers and
Practices of Swedish Lifestyle Movers in Malta, Dissertation, Umeå
University, Department of Geography and Economic History, GERUM 2013:2
Öström, Nils (2009) 30 års bistånd till Nicaragua [30 years’ development aid
to Nicaragua], December 15 2009, unpublished report
Öström, Nils and Lewin, Elisabeth (2009) Outcome Assessment of Swedish
Cooperation with Nicaragua 2001-2008, unpublished report, see:
http://www.sida.se/Global/Countries%20and%20regions/Latin%20Americ
a/Nicaragua/Outcome%20_Assessment%20_Nicaragua%20_2001_2008.p
df
Internet sources
AnthroBase.com, homepage, accessed 2014-03-21,
http://www.anthrobase.com/About/about.htm
Arvidsen, Ivar/Fria.nu (August 30 2007) Färre länder får svenska
biståndspengar, [Fewer countries receive Swedish aid], accessed 2013-10-01,
http://www.fria.nu/artikel/19803
GFMD, homepage, accessed 2014-01-07, http://www.gfmd.org/en/
INDEPTH Network, homepage, accessed 2013-04-26, http://www.indepthnetwork.org/
INIDE, homepage, data accessed 2013-11-28,
http://www.inide.gob.ni/censos2005/CifrasMun/Tablaincidencia.pdf
LABORSTA, ILO database, accessed 2012-06-29,
http://laborsta.ilo.org/default.html
UNESCO, homepage, accessed 2014-02-13,
http://stats.uis.unesco.org/unesco/TableViewer/document.aspx?ReportId=
124&IF_Language=eng&BR_Country=5580&BR_Region=40520
UN DESA, homepage, accessed 2012-06-20,
http://esa.un.org/unpd/wpp/unpp/panel_indicators.htm
UN DESA, World Population Prospects, the 2010 revision, accessed 201209-28 and 2014-02-16, http://esa.un.org/unpd/wpp/ExcelData/population.htm
UN DESA, Trends in International Migrant Stock: The 2008 Revision,
accessed 2014-01-07, http://esa.un.org/migration/index.asp?panel=1
UN DESA, High-Level Dialogue on International Migration and
Development, homepage, accessed 2014-01-07,
http://www.un.org/esa/population/meetings/HLD2013/mainhld2013.html
328
UN, Millenium Development Goals Indicators, accesssed 2011-11-30,
http://mdgs.un.org/unsd/mdg/Data.aspx
UNDP, Human Development Indicators, accessed 2012-06-25,
http://hdrstats.undp.org/en/countries/profiles/NIC.html,
UNDP, International Human Development Indicators, accessed 2011-11-30,
http://hdrstats.undp.org/en/countries/profiles/NIC.html
UNdata, United Nations Statistics Division, accessed 2014-02-13,
http://data.un.org/Explorer.aspx?d=WDI
United States Border Patrol, homepage, accessed 2014-11-30,
http://www.cbp.gov/sites/default/files/documents/U.S.%20Border%20Patr
ol%20Fiscal%20Year%20Statistics%20SWB%20Sector%20Deaths%20FY19
98%20-%20FY2013.pdf
329
Appendix: Survey 2008
CENTRE FOR DEMOGRAPHIC AND HEALTH RESEARCH (CIDS), UNIVERSITY OF LEÓN
HEALTH AND DEMOGRAPHIC SURVEILLANCE SYSTEMS - LEÓN AND NORTHERN ZONE OF CHINANDEGA
UMEÅ UNIVERSITY, DEPARTMENT OF SOCIAL AND ECONOMIC GEOGRAPHY
SURVEY: “MIGRATION, HEALTH AND SOCIAL NETWORKS” 2008
FOR SUPERVISOR'S USE:
FOR QUALITY CONTROL:
FIELDWORKER'S CODE:
DATE (D/M/Y):
QUESTIONNAIRE NO:
NAME OF RESPONDENT:
INDIVIDUAL CODE:
HOUSEHOLD CODE:
ABBREVIATIONS:
(1) = 1 option/answer
R (1) = read all options, 1 answer
(M) = multiple options/answers
 = move on to question…
A. MIGRATION
1
1. Within the municipality 2. In another municipality
3. In another department 4. In another country
Where were you born?
a) How many places have you lived in,
besides your place of birth?
2
3
4
b) Where? (Fill in number of
places for each category)
Number: ___ ("0"  3)
1. Yes 2. Maybe 3. Don't know ( 6)
4. No ( 6)
1. Within the municipality
3. In another department
Where?
(1)
1. Within the municipality __ 2. In another municipality __
3. In another department __ 4. In another country __
Have you thought about moving
somewhere else?
(1)
(M)
(1)
2. In another municipality
4. In another country
5. Don't know
Specify location(s):
1. __________ 2. __________ 3. __________ 4. __________
5
Why have you
thought of moving
there?
1. Unemployment/lack of income 2. To work/better job 3. To study
4. To live with or help relatives 5. To help family members (who stay)
6. Family problems 7. Health problem or death of relative
8. Other problem (of relative) 9. Personal health problems 10. Other
problem (own) 11. To try another way of life 12. Environmental
reasons 13. Don't know 14. Other, specify ____________________
6
Do you have relatives who live in other places?
7
Who? Where do they live?
1. Yes 2. No ( 8)
(M)
(M)
(1)
Fill in number of persons per family category, and place of residence for each person.
1. Spouse/partner
2. Child, no. ___
3. Parent, no. ___
4. Sibling, no.___
5. Grandparent, no.___
6. Other, no.___
Where: _________________
Where: _________________
Where: _________________
Where: _________________
Where: _________________
Where: _________________
Where:
1. In the same municipality
2. In another municipality
3. In another department
4. In another country
(specify)
“MIGRATION, HEALTH AND SOCIAL NETWORKS”, CIDS and Umeå University, 2008
p. 1 (of 6)
(M)
Appendix: Survey 2008
B. HEALTH
Make sure the respondent knows what physical health means.
8
a) In general, how is your
physical health condition?
1. Excellent
4. Bad
2. Very good 3. Good
5. Very bad
b) How is your physical health
condition today, compared to
six months ago?
1. Much better 2. Better
3. The same
4. Worse
5. Much worse
R
(1)
Make sure the respondent knows what mental health means
(symptoms like sadness, tiredness, sleeping disorders, melancholy, worry, tension, stress, etc.).
9
10
a) In general, how is your
mental health condition?
1. Excellent
4. Bad
2. Very good 3. Good
5. Very bad
b) How is your mental health
condition today, compared to
six months ago?
1. Much better 2. Better
3. The same
4. Worse
5. Much worse
a) Have you been sick in the
past three months?
1. Yes 2. No ( 13)
b) In what way? (which
illness/disease)
c) Did you use any
health service(s)?
d) Did you use any
medicine or home
remedies?
1.________________________
2.________________________
3.________________________
4.________________________
5.________________________
1._____________
2._____________
3._____________
4._____________
5._____________
1._____________
2._____________
3._____________
4._____________
5._____________
Fill in both acute and chronic
illnesses/diseases. Fill in the five
most serious health problems if the
person states more than five.
1. Health post 2. Health
centre 3. Hospital 4. “Casa
base” (basic care) 5. Healer
6. Private clinic 7. Didn't
have access 8. Selfmedicated 9. Didn't go
1. Occidental medicine
2. Traditional medicine
3. Other, specify
4. None
R
(1)
(1)
(M)
Questions 11-12 are only for those who answered that they used public health care
(options 1-4 in question 10c). If not, continue with question 13.
11
How was the quality of attention at
the public health care facility/ies?
1. Sufficient/good ( 13)
2. Insufficient/bad
R
(1)
12
Why was it insufficient/bad?
1. Bad communication with doctor 2. Bad medical
skills 3. Bad quality of attention 4. Distance to
the facility too far 5. The facility didn't have enough
resources (for exams, medicine, etc.) 6. Lack of
privacy 7. Other, specify_________________
(M)
13
Do you have social insurance?
1. Yes 2. No
(1)
“MIGRATION, HEALTH AND SOCIAL NETWORKS”, CIDS and Umeå University, 2008
p. 2 (of 6)
Appendix: Survey 2008
C. SOCIAL NETWORK AND HELP/SUPPORT
a) Do you feel you have someone to turn to for
economic support if you experience some kind
of problem – for instance with your health?
14
b) Who?
1. Yes 2. No 3. Don't know ( 15)
(1)
1. Spouse/partner
2. Child
3. Parent
4. Sibling
5. Grandparent
6. Other relative
7. Friend
8. Neighbour
9. Employer
10. Teacher
11. Community leader 12. Priest
13. Organization, specify ___________________________
14. Other, specify ________________________________
(M)
a) Do you feel you have someone with whom you
can share your most inner feelings or personal
problems, or someone to confide in?
1. Spouse/partner
2. Child
3. Parent
4. Sibling
5. Grandparent
6. Other relative
7. Friend
8. Neighbour
9. Employer
10. Teacher
11. Community leader 12. Priest
13. Organization, specify ___________________________
14. Other, specify ________________________________
15
b) Who?
16
1. Yes 2. No 3. Don't know ( 15)
a) Do you ever receive help from someone
who lives in another place?
b) From whom?
1. Spouse/partner
2. Child, no. ___
3. Parent, no. ___
4. Sibling, no.___
5. Grandparent, no.___
6. Other relative, no.___
7. Friend, no.___
8. Other, no.___
specify__________
(1)
(M)
1. Yes
2. No (never have) ( 17)
3. No (but did earlier) ( 17)
(1)
c) Where do(es)
he/she/they live?
d) What type(s) of help do you
receive?
(M)
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
1. Same municipality
2. Other municipality
3. Other department
4. Other country
5. Don't know
1. Money 2. Utilities (clothes, TV,
cosmetics, etc.) 3. Food 4. Medicine
5. Care/help/support 6. Labour
7. Transport 8. Information
9. Emotional support 10. Other,
specify_____________________
Questions 16 e-g (below) are only for those who answered "money" (in question 16d).
If not, continue with question 17.
e) How often do you receive money?
___times every: __week/__month/__year
From: _________________
f) How great a part of the household income
1. Small part
2. Large part
does the money you receive constitute?
3. Medium part
g) What do you
normally use the
money for?
R
(1)
1. Food/living expenses 2. Education 3. Housing (buy/build new,
repairs) 4. Clothes 5. Health expenses 6. Savings 7. Business (start
new, expand) 8. Pay off debts 9. Recreation/vacation 10.
Party/ceremony 11. Acquisition (vehicles, animals, tools, agricultural
supplies) 12. Other, specify _______________________________
“MIGRATION, HEALTH AND SOCIAL NETWORKS”, CIDS and Umeå University, 2008
(1)
p. 3 (of 6)
(M)
Appendix: Survey 2008
C. SOCIAL NETWORK AND HELP/SUPPORT (cont.)
Question 17 is only for those who responded that they had been sick (in question 10).
If not, continue with question 18.
17
a) Did anyone (person or organization) help
you in some way when you were sick?
b) Who?
1. Spouse/partner
2. Child, no. ___
3. Parent, no. ___
4. Sibling, no.___
5. Grandparent, no.___
6. Other relative, no.___
7. Friend, no.___
8. Other, no.___
specify___________
1. Yes
2. No ( 18)
(1)
c) Where do(es)
he/she/they live?
d) What type(s) of help did you
receive?
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
1. Same municipality
2. Other municipality
3. Other department
4. Other country
5. Don't know
1. Money 2. Medicine 3. Care/help
4. Food 5. Transport 6. Information
7. Labour 8. Emotional support
9. Other, specify________________
(M)
Questions 17 e-f (below) are only for those who answered "money" (in question 17d).
If not, continue with question 18.
18
e) What did you use the money for?
f) In relation to what illness?
1. Buy medicine
2. Visit private clinic (for exams, etc.)
3. Transport (to health service)
4. Other, specify ___________________
_________________
_________________
_________________
_________________
a) Do you (occasionally or more often) help
someone who lives in another place?
b) Who?
1. Spouse/partner
2. Child no. ___
3. Parent no. ___
4. Sibling no.___
5. Grandparent no.___
6. Other relative no.___
7. Friend no.___
8. Other no.___
specify_____________
1. Yes
(M)
2. No ( 19)
(1)
c) Where do(es)
he/she/they live?
d) What type(s) of help do you
provide to the person?
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
1. Same municipality
2. Other municipality
3. Other department
4. Other country
5. Don't know
1. Money 2. Utilities (clothes, TV,
cosmetics, etc.) 3. Food 4. Medicine
5. Care/help/support 6. Labour
7. Transport 8. Information
9. Emotional support 10. Other,
specify________________
(M)
Question 18 e (below) is only for those who answered "money" (in question 18d).
If not, continue with question 19.
e) What do(es)
he/she/they
normally use
the money for?
1. Alimentation/living expenses 2. Education 3. Housing (buy/build new,
repairs) 4. Clothes 5. Health expenses 6. Savings 7. Business (start
new, expand) 8. Pay off debts 9. Recreation/vacation 10. Party/ceremony
11. Acquisition (vehicles, animals, tools, agricultural supplies)
12. Other, specify __________________________ 13. Don’t know
“MIGRATION, HEALTH AND SOCIAL NETWORKS”, CIDS and Umeå University, 2008
p. 4 (of 6)
(M)
Appendix: Survey 2008
C. SOCIAL NETWORK AND HELP/SUPPORT (cont.)
Questions 19-22 are only for those who have relatives living outside Nicaragua (see question 7).
If not, continue with question 23.
19
a) In what ways can you maintain contact with
your relatives who live outside Nicaragua?
b) How often do you have contact?
Only fill in the ways of contact mentioned in
(a). Fill in the frequency of contact for each
type, and mark with X whether this is per
week (W), month (M) or year (Y). If the
respondent has contact with various
relatives, fill in the highest frequency.
20
1. Telephone 2. Internet 3. Letters
4. Messages/greetings
5. Visits
6. No way ( 20)
7. Other,
specify _____________________
1. Telephone
2. Internet
3. Letters
4. Messages
5. Visits
6. Other
__times every:
__times every:
__times every:
__times every:
__times every:
__times every:
__W/__M/__Y
__W/__M/__Y
__W/__M/__Y
__W/__M/__Y
__W/__M/__Y
__W/__M/__Y
(M)
(M)
Do your family members who live outside Nicaragua have (legal) “documents”?
(that is, do they have their papers in order?)
1. Spouse/partner
2. Child
3. Parent
4. Sibling
5. Grandparent
6. Other
1. Yes ___
1. Yes ___
1. Yes ___
1. Yes ___
1. Yes ___
1. Yes ___
2. No ___
2. No ___
2. No ___
2. No ___
2. No ___
2. No ___
3. Don't know ___
3. Don't know ___
3. Don't know ___
3. Don't know ___
3. Don't know ___
3. Don't know ___
(M)
Fill in the number of persons per category.
Question 21 (below) is only for those who have children living abroad (see question 7).
If not, continue with question 22.
a) How are the living conditions for your child(ren) who live(s) outside Nicaragua,
according to you?
21
Regarding:
Fill in the number of children for each category.
A. Work
1. Good __ 2. Regular __ 3. Bad __ 4. Don't know __ 99*
B. Studies
1. Good __ 2. Regular __ 3. Bad __ 4. Don't know __ 99*
C. Housing
1. Good __ 2. Regular __ 3. Bad __ 4. Don't know __
D. Health
1. Good __ 2. Regular __ 3. Bad __ 4. Don't know __
E. Social life 1. Good __ 2. Regular __ 3. Bad __ 4. Don't know __
Comment:
(M)
* Not applicable
b) Do(es) he/she/they have any
relatives living close by? (in the
same town/city)
1. Yes ___ 2. No ___ 3. Don't know ___
Fill in the number of children for each category.
“MIGRATION, HEALTH AND SOCIAL NETWORKS”, CIDS and Umeå University, 2008
p. 5 (of 6)
Appendix: Survey 2008
C. SOCIAL NETWORK AND HELP/SUPPORT (cont.)
Question 22 is only for those whose spouse/partner lives abroad (see question 7).
If not, continue with question 23.
22
a) How are the living conditions for your spouse/partner who lives outside
Nicaragua, according to you?
Regarding:
A. Work
B. Studies
C. Housing
D. Health
E. Social life
Comment:
1. Good
1. Good
1. Good
1. Good
1. Good
2. Regular
2. Regular
2. Regular
2. Regular
2. Regular
3. Bad
3. Bad
3. Bad
3. Bad
3. Bad
4. Don't know
4. Don't know
4. Don't know
4. Don't know
4. Don't know
99*
99*
R
(1)
* Not applicable
b) Does he/she have any relatives living close
by? (in the same town/city)
1. Yes
2. No
3. Don't know
(1)
According to you, how are the living conditions for Nicaraguans in general who
live abroad, compared to the living conditions in Nicaragua?
23
Regarding:
A. Work
B. Studies
C. Housing
D. Health
E. Social life
Comment:
1. Better
1. Better
1. Better
1. Better
1. Better
2. The same
2. The same
2. The same
2. The same
2. The same
3. Worse
3. Worse
3. Worse
3. Worse
3. Worse
4. Don't know
4. Don't know
4. Don't know
4. Don't know
4. Don't know
R
(1)
24
Do you participate in any
organization or in social
(community) activities?
1. Yes, political
2. Yes, religious
3. Yes, social
4. Yes, voluntary
5. Yes, cultural
6. Yes, other, specify _____________ 7. No
(M)
25
Do you like the place where you
live?
1. I like it a lot
(1)
2. I like it a little
3. I don't like it
Finally, I would like to ask some questions regarding your neighbourhood/
community.
26
a) Would you appreciate it if the neighbours
helped each other……………………………………………..
MORE__, LESS__, THE SAME__ ?
b) Would you appreciate it if the neighbours
took care of each other……….………….…………………..
MORE__, LESS__, THE SAME__ ?
c) Would you appreciate it if the neighbours cared for
and looked after each other’s children……..…………..
MORE__, LESS__, THE SAME__ ?
d) Would you appreciate it if the neighbours
participated in social/community activities…………
MORE__, LESS__, THE SAME__ ?
THANK YOU FOR YOUR PARTICIPATION!
COMMENTS:______________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
“MIGRATION, HEALTH AND SOCIAL NETWORKS”, CIDS and Umeå University, 2008
p. 6 (of 6)
R
(1)
Avhandlingar i kulturgeografi
Jonsson, Ingvar (1971): Jordskatt och kameral organisation i Norrland under äldre tid.
Geografiska meddelanden nr 7.
Häggström, Nils (1971): Norrland’s Direct Foreign Trade 1850-1914. Geographical Reports No
2.
Borgegård, Lars-Erik (1973): Tjärhantering i Västerbottens län under 1800-talets senare
hälft. Geografiska meddelanden nr 13.
Weissglas, Gösta (1975): Studies on Service Problems in the Sparsely Populated Areas in
Northern Sweden. Geographical Reports No 5.
Liljenäs, Ingrid (1977): Allmänningsskogarna i Norrbottens län – deras betydelse för det
enskilda jord- och skogsbruket. Geografiska meddelanden nr 23.
Arell, Nils (1977): Rennomadismen i Torne lappmark – markanvändning under kolonisationsepoken i framför allt Enontekis socken. Geografiska meddelanden nr 24.
Nordberg, Perola (1977): Ljungan. Vattenbyggnader i den näringsgeografiska miljön 15501940. Geografiska meddelanden nr 25.
Layton, Ian (1981): The Evolution of Upper Norrland’s Ports and Loading Place 1750-1976.
Geographical Reports No 6.
Khakee, Abdul (1983): Municipal Planning. Restrictions, Methods and Organizational
Problems. Geografiska meddelanden nr 27.
Wiberg, Ulf (1983): Service i glesbygd – trender och planeringsmöjligheter. GERUM rapport
B:8.
Holm, Einar (1984): Att lokalisera utbildning, sysselsättning och boende. GERUM rapport
B:9.
Lövgren, Sture (1986): Så växer tätorten – diskussion om en modell för urban utredning.
GERUM rapport nr 5.
Egerbladh, Inez (1987): Agrara bebyggelseprocesser. Utvecklingen i Norrbottens kustland
fram till 1900-talet. GERUM rapport nr 7.
Johnsson, Rolf S (1987): Jordbrukspolitiska stödformer – en studie av SR-, A- och B-stödens
lokala effekter 1961-1981. GERUM rapport nr 11.
Malmberg, Gunnar (1988): Metropolitan Growth and Migration in Peru. Geographical
Reports No 9.
Sivertun, Åke (1993): Geographical Information Systems (GIS) as a Tool for Analysis and
Communication of Complex Data. Geographical Reports No 10.
Westin, Kerstin (1994): Valuation of Goods Transportation Characteristics – A Study of a
Sparsely Populated Area. Geographical Reports No 12.
Jansson, Bruno (1994): Borta bra men hemma bäst – Svenskars turistresor i Sverige under
sommaren. GERUM rapport nr 22.
Lindgren, Urban (1997): Local Impacts of Large Investments. GERUM kulturgeografi 1997:2.
Stjernström, Olof (1998): Flytta nära, långt bort. De sociala nätverkens betydelse för val av
bostadsort. GERUM kulturgeografi 1998:1.
Müller, Dieter (1999): German Second Home Owners in the Swedish Countryside. GERUM
kulturgeografi 1999:2.
Håkansson, Johan (2000): Changing Population Distribution in Sweden – Long Term Trends
and Contemporary Tendencies. GERUM kulturgeografi 2000:1.
Tollefsen Altamirano, Aina (2000): Seasons of Migration to the North. A Study of Biographies
and Narrative Identities in US-Mexican and Swedish-Chilean Return Movements. GERUM
kulturgeografi 2000:3.
Nilsson, Karina (2001): Migration among young men and women in Sweden. GERUM
kulturgeografi 2001:2.
Appelblad, Håkan (2001): The Spawning Salmon as a Resource by Recreational Use. The case
of the wild Baltic salmon and conditions for angling in north Swedish rivers. GERUM
kulturgeografi 2001:3.
Alfredsson, Eva (2002): Green Consumption Energy Use and Carbon Dioxide Emissions.
GERUM kulturgeografi 2002:1.
Pettersson, Örjan (2002): Socio-Economic Dynamics in Sparse Regional Structures. GERUM
kulturgeografi 2002:2.
Abramsson, Marianne (2003): Housing Careers in a Changing Welfare State. GERUM
kulturgeografi 2003:1.
Strömgren, Magnus (2003): Spatial Diffusion of Telemedicine in Sweden. GERUM
kulturgeografi 2003:2.
Jonsson, Gunilla (2003): Rotad, rotlös, rastlös – Ung mobilitet i tid och rum. GERUM
kulturgeografi 2003:3.
Pettersson, Robert (2004): Sami Tourism in Northern Sweden – Supply, Demand and
Interaction. GERUM kulturgeografi 2004:1.
Brandt, Backa Fredrik (2005): Botniabanan – Förväntningar i tid och rum på regional
utveckling och resande. GERUM kulturgeografi 2005:4.
Helgesson, Linda (2006): Getting Ready for Life – Life Strategies of Town Youth in
Mozambique and Tanzania. GERUM kulturgeografi 2006:1.
Lundmark, Linda (2006): Restructuring and Employment Change in Sparsely Populated
Areas. Examples from Northern Sweden and Finland. GERUM kulturgeografi 2006:2.
Li, Wenjuan (2007): Firms and People in Place. Driving Forces for Regional Growth. GERUM
kulturgeografi 2007:1.
Lundholm, Emma (2007): New Motives for Migration? On Interregional Mobility in the
Nordic Context. GERUM kulturgeografi 2007:2.
Zillinger, Malin (2007): Guided Tourism - the Role of Guidebooks in German Tourist
Behaviour in Sweden. GERUM kulturgeografi 2007:3.
Marjavaara, Roger (2008): Second Home Tourism. The Root to Displacement in Sweden?
GERUM kulturgeografi 2008:1.
Sörensson, Erika (2008): Making a Living in the World of Tourism. Livelihoods in
Backpacker Tourism in Urban Indonesia. GERUM kulturgeografi 2008:2.
Hjort, Susanne (2009): Socio-economic Differentiation and Selective Migration in Rural and
Urban Sweden. GERUM kulturgeografi 2009:1.
Eriksson, Rikard (2009): Labour Mobility and Plant Performance. The influence of
proximity, relatedness and agglomeration. GERUM kulturgeografi 2009:2.
Khouangvichit, Damdouane (2010): Socio-Economic Transformation and Gender Relations
in Lao PDR. GERUM kulturgeografi 2010:1.
Eriksson, Madeleine (2010): (Re)producing a periphery - popular representations of the
Swedish North. GERUM kulturgeografi 2010:2.
Phouxay, Kabmanivanh (2010): Patterns of Migration and Socio-Economic Change in Lao
PDR. GERUM kulturgeografi 2010:3.
Hjälm, Anna (2011): A family landscape. On the geographical distances between elderly
parents and adult children in Sweden. GERUM kulturgeografi 2011:1.
Sandow, Erika (2011): On the road. Social aspects of commuting long distances to work.
GERUM kulturgeografi 2011:2.
Sandberg, Linda (2011): Fear of violence and gendered power relations. Responses to threat
in public space in Sweden. GERUM kulturgeografi 2011:3.
Phommavong, Saithong (2011): International Tourism Development and Poverty Reduction
in Lao PDR. GERUM kulturgeografi 2011:4.
Haugen, Katarina (2012): The accessibility paradox – everyday geographies of proximity,
distance and mobility. GERUM kulturgeografi 2012:1.
Olofsson, Jenny (2012): Go West – East European Migrants in Sweden. GERUM
kulturgeografi 2012:2.
Ouma, Anne (2013): From Rural Gift to Urban Commodity – Traditional Medicinal
Knowledge and Socio-spatial Transformation in the Eastern Lake Victoria Region. GERUM
kulturgeografi 2013:1.
Åkerlund, Ulrika (2013): The Best of Both Worlds – Aspirations, Drivers and Practices of
Swedish Lifestyle Movers in Malta. GERUM kulturgeografi 2013:2.
Olsson, Olof (2014): Out of the Wild: Studies on the forest as a recreational resource for urban
residents. GERUM kulturgeografi 2014:1.
GERUM kulturgeografi
(1997-20xx)
(ISSN 1402-5205)
1997:1
Holm, E. (ed.): Modelling Space and Networks. Progress in Theoretical and
Quantitative Geography.
1997:2
Lindgren, U.: Local Impacts of Large Investments. (Akad. avh.)
1998:1
Stjernström, O.: Flytta nära, långt bort. De sociala nätverkens betydelse för val
av bostadsort. (Akad. avh.)
1998:2
Andersson, E.; L.-E. Borgegård och S. Hjort: Boendesegregation i de nordiska
huvudstadsregionerna.
1999:1
Stjernström, O. & I. Svensson: Kommunerna och avfallet. Planering och hantering av farligt avfall, exemplen Umeå och Gotland.
1999:2
Müller, D.: German Second Home Owners in the Swedish Countryside. (Akad.
avh.)
2000:1
Håkansson, J.: Changing Population Distribution in Sweden – Long Term Trends
and Contemporary Tendencies. (Akad. avh.)
2000:2
Helgesson, L.: Högutbildad, men diskvalificerad. Några invandrares röster om
den svenska arbetsmarknaden och vägen dit.
2000:3
Tollefsen Altamirano, A.: Seasons of Migrations to the North. A Study of
Biographies and Narrative Identities in US-Mexican and Swedish-Chilean
Return Movements. (Akad. avh.)
2001:1
Alatalo, M.: Sportfisketurism i Västerbottens läns inlands- och fjällområde. Om
naturresursanvändning i förändring. (Lic. avh.)
2001:2
Nilsson, K.: Migration among young men and women in Sweden. (Akad. avh.)
2001:3
Appelblad, H.: The Spawning Salmon as a Resource by Recreational Use. The case
of the wild Baltic salmon and conditions for angling in north Swedish rivers.
(Akad. avh.)
2001:4
Pettersson, R.: Sami Tourism - Supply and Demand. Two Essays on Indigenous
Peoples and Tourism in Sweden. (Lic. avh.)
2002:1
Alfredsson, E.: Green Consumption Energy Use and Carbon Dioxide Emissions.
(Akad. avh.)
2002:2
Pettersson, Ö.: Socio-Economic Dynamics in Sparse Regional Structures. (Akad.
avh.)
2002:3
Malmberg, G. (red.): Befolkningen spelar roll.
2002:4
Holm, E.; Holme, K.; Mäkilä, K.; Mattsson-Kauppi, M. & G. Mörtvik: The SVERIGE
spatial microsimulation model. Content validation, and example applications.
2003:1
Abramsson, M.: Housing Careers in a Changing Welfare State. (Akad. avh.)
2003:2
Strömgren, M.: Spatial Diffusion of Telemedicine in Sweden. (Akad. avh.)
2003:3
Jonsson, G.: Rotad, rotlös, rastlös – Ung mobilitet i tid och rum. (Akad. avh.)
2004:1
Pettersson, R.: Sami Tourism in Northern Sweden – Supply, Demand and
Interaction. (Akad. avh.)
2005:1
Hjort, S.: Rural migration in Sweden: a new green wave or a blue ripple? (Lic.
avh.)
2005:2
Malmberg, G.: Sandberg, L. & Westin, K.: Den goda platsen. Platsanknytning och
flyttningsbeslut bland unga vuxna i Sverige.
2005:3
Lundgren, A.: Microsimulation and tourism forecasts. (Lic. avh.)
2005:4
Brandt, B. F.: Botniabanan – Förväntningar i tid och rum på regional utveckling
och resande. (Akad. avh.)
2006:1
Helgesson, L.: Getting Ready for Life – Life Strategies of Town Youth in Mozambique and Tanzania. (Akad. avh.)
2006:2
Lundmark, L.: Restructuring and Employment Change in Sparsely Populated
Areas. Examples from Northern Sweden and Finland. (Akad. avh.)
2007:1
Li, W.: Firms and People in Place. Driving Forces for Regional Growth. (Akad.
avh.)
2007:2
Lundholm, E.: New Motives for Migration? On Interregional Mobility in the
Nordic Context. (Akad. avh.)
2007:3
Zillinger, M.: Guided Tourism - the Role of Guidebooks in German Tourist
Behaviour in Sweden. (Akad. avh.)
2008:1
Marjavaara, R.: Second Home Tourism. The Root to Displacement in Sweden?
(Akad. avh.)
2008:2
Sörensson, E.: Making a Living in the World of Tourism. Livelihoods in
Backpacker Tourism in Urban Indonesia. (Akad. avh.)
2009:1
Hjort, S.: Socio-economic differentiation and selective migration in rural and
urban Sweden. (Akad. avh.)
2009:2
Eriksson, R.: Labour Mobility and Plant Performance. The influence of proximity,
relatedness and agglomeration. (Akad. avh.)
2010:1
Khouangvichit, D.: Socio-Economic Transformation and Gender Relations in Lao
PDR. (Akad. avh.)
2010:2
Eriksson, M.: (Re)producing a periphery - popular representations of the Swedish
North. (Akad. avh.)
2010:3
Phouxay, K.: Patterns of Migration and Socio-Economic Change in Lao PDR.
(Akad. avh.)
2011:1
Hjälm, A.: A family landscape. On the geographical distances between elderly
parents and adult children in Sweden. (Akad. avh.)
2011:2
Sandow, E.: On the road. Social aspects of commuting long distances to work.
(Akad. avh.)
2011:3
Sandberg, L.: Fear of violence and gendered power relations. Responses to threat
in public space in Sweden. (Akad. avh.)
2011:4
Phommavong, S.: International Tourism Development and Poverty Reduction in
Lao PDR. (Akad. avh.)
2012:1
Haugen, K.: The accessibility paradox – everyday geographies of proximity,
distance and mobility. (Akad. avh.)
2012:2
Olofsson, J.: Go West – East European Migrants in Sweden. (Akad. avh.)
2013:1
Ouma, A.: From Rural Gift to Urban Commodity – Traditional Medicinal
Knowledge and Socio-spatial Transformation in the Eastern Lake Victoria
Region. (Akad. avh.)
2013:2
Åkerlund, U.: The Best of Both Worlds – Aspirations, Drivers and Practices of
Swedish Lifestyle Movers in Malta. (Akad. avh.)
2014:1
Olsson, O.: Out of the Wild: Studies on the forest as a recreational resource for
urban residents. (Akad. avh.)
2014:2
Gustafsson, C.: ”For a better life…” – A study on migration and health in
Nicaragua. (Akad. avh.)
Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Related manuals

Download PDF

advertisement