“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 (MH), 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 (MH), 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. 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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. 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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.)
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