More than 60 percent of the world’s refugees and 80 percent of internally displaced persons (IDPs) now live in urban areas. In contrast to traditional refugee camps, which have mainly been in rural areas, cities and other urban settings can offer refugees greater economic opportunities, a degree of anonymity, and better access to services—at least in theory, said Mary Nell, executive director of the Maternal Health Task Force, at the Wilson Center on May 31. However, in practice, the urban advantage may be a myth, as local systems, already strained by growing populations, are not well equipped to handle a large influx of people with complex needs.

A “Right to the City” for Displaced People

Poor urban dwellers, including many refugees and IDPs, live in areas of the city that lack public services so they struggle to maintain their health due to high transportation costs, inadequate toilet and sanitation facilities, contaminated drinking and domestic water, overcrowding, and spread of communicable diseases. Samer Saliba, an urban technician with the International Rescue Committee, said that humanitarian workers “need to understand how to operate within a larger dynamic that’s happening, as well as a more complicated and constantly changing space that is the city.”

In addition to the challenges faced by all poor urban dwellers, refugees and IDPs have to overcome hurdles unique to their status. They are mobile; they arrive poor; they lack a support system and a social network; and they often face language barriers. Dr. Stephanie Kayden, chief of the division of International Emergency Medicine and the Humanitarian Program at Brigham and Women’s Hospital, said that knowing the local language is critical to accessing higher level secondary healthcare services, especially prenatal and postpartum care. Additionally, refugees have to navigate a complex legal landscape. In Egypt, the displaced population is often afraid to register with local authorities and obtain the ID card necessary to use health services, said Sarah Ashraf, advisor for reproductive health in emergencies at Save the Children. Finally, successive waves of migration affect family structure, separating members and causing trauma.

To best integrate displaced people, humanitarian workers need to establish a right to the city

To best integrate displaced people, humanitarian workers need to establish a right to the city, defined by the International Rescue Committee as “an urban dweller’s ability to safely and fairly access public and social services, opportunities for self-sustainability, education, employment, healthcare, and safe and welcoming environments in which to reside.” Saliba suggested that humanitarians need to make pre-existing public service delivery systems more inclusive and better adapted to the needs of displaced and marginalized residents. To accomplish this, aid actors must understand the complexity of the city and engage in local-level collaboration, systems strengthening, organizational development, and advocacy, he said.

 Maternal and Newborn Health Challenges Facing Urban Refugees

Infant mortality is lower in urban areas than rural areas, according to WHO. However, this is not true across all areas of cities. Infant mortality, in fact, increases in urban slums, which are often the cost-effective neighborhoods where refugees live, said Kayden. This urban disadvantage in maternal health outcomes is largely due to the dearth of skilled birth attendants, such as doctors and midwives, in poor urban areas. “About 5 to 15 percent of all deliveries will run into a complication that requires some sort of surgical intervention,” added Kayden, and the absence of health professionals further endangers mothers.

Infant mortality, in fact, increases in urban slums

Some displaced people are not able to obtain refugee status and therefore do not have even the limited protections afforded to refugees. Alicia Wilson, the executive director at La Clinica del Pueblo, said the Latino migrant community is one of the fastest growing populations without refugee status in Washington, D.C, and therefore lacks adequate medical safety nets. In the latest wave of migration to the United States, unaccompanied minors arriving on the southern border from Central America faced threats from gangs in their home country, harassment from coyotes, and kidnapping. Adolescent girls who migrate do not escape gender-based violence when they reach the United States. Some coyotes not only abuse them both physically and sexually but also control their finances, trapping the girls in debt bondage.

A disproportionate number of pre-natal patients at La Clinica are under the age of 19. As young, migrant, pregnant women, they face persistent stress, fear, trauma, and anxiety, as well as challenges arising from their cultural norms and gender roles.  “We have many female patients who are in abusive relationships and who feel they are unable to leave because their partner controls their immigration status,” said Wilson. La Clinica works to mitigate the impacts of sexual and gender-based violence through the Entre Amigas program, a gender-based peer support health program that helps girls navigate issues of reproductive health and domestic violence.  Due to an increasing distrust in formal institutions, displaced communities largely rely on informal networks like Entre Amigas and other programs run by non-governmental organizations.

Building a Safety Net

“Humanitarian actors are trying to deal with a crisis in a city, and local authorities are trying to manage a city in crisis,” said Saliba. “We, as humanitarians, just land in a city and don’t often take the time to say ‘hello’ to the public service providers in the existing systems and stakeholders that are there.” Identifying possible collaborations with existing service providers is a possible remedy. For example, through the Amman Resilience Strategy, the International Rescue Committee worked with Amman’s public service providers to help rewrite their resilience strategy to make it more inclusive of the needs of displaced and marginalized populations at the municipal, national, and international levels.

“Humanitarian actors are trying to deal with a crisis in a city, and local authorities are trying to manage a city in crisis”

To improve urban maternal healthcare, Kayden called for enhancing local public health infrastructure, along with more outreach, education, and advocacy. Community health centers, for example, can act as shared “child friendly” spaces for informal education, health access, and conflict resolution. At Save the Children’s community centers in Egypt, refugees belonging to different nationalities can access a variety of social and health services. “Implementing a reproductive health program in those settings through the public health system by training on family planning showed a remarkable result for us,” said Ashraf. Since 2016, about 60 percent of the women in Save the Children’s program have chosen long-acting reversible contraceptive methods. But reproductive and maternal services can still be expensive and low quality. Ashraf suggested that humanitarian actors develop strategies to improve secondary health care facilities to improve quality and cost-effectiveness.

To serve mothers and newborns who are most in need, “we need to constantly be refreshing our services and approach,” said Wilson. She advocated for a community-centered, collaborative approach at all levels: “Sharing our lessons learned with other providers [is important] so that we can build a safety net that’s beyond our four walls, toward a much more enhanced, welcoming community for newly arrived folks.”

Event Resources

• Alicia Wilson’s Presentation
• Samer Saliba’s Presentation
• Sarah Ashraf’s Presentation
• Stephanie Kayden’s Presentation

• Photo Gallery

Written by Namita Rao, edited by Francesca Cameron and Meaghan Parker.

Cover photo credit: Patients in a Mexico City clinic, November 2015, courtesy of the Pan American Health Organization.

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