The state of the world's refugees: adapting health responses to urban environments.

THE FORCED DISPLACEMENT OF POPULATIONS, ACROSS borders and within their own countries, is one of the most visible and enduring manifestations of persecution and conflict. At the end of 2011, more than 42 million people had been forcibly displaced from their homes by conflict, including 15 million refugees and 26 million internally displaced people (IDPs). In 2011, more than 4.3 million people were newly uprooted, with some 800 000 fleeing to neighboring countries in humanitarian crises stretching from Côte d’Ivoire, Libya, Syria, the border between Sudan and South Sudan, to the Horn of Africa and more recently due to conflict in Mali. These new emergencies unfolded alongside unresolved crises that have resulted in millions of people living in situations of protracted displacement, often for decades. Millions of refugees and IDPs from countries such as Somalia, Afghanistan, Eritrea, Colombia, the Democratic Republic of Congo, and Iraq remain unable to return to their homes after extended periods in exile. The vast majority of refugees— approximately 80%—are hosted in the developing world, primarily in neighboring countries. The challenges of responding to forced displacement have been shaped over the past decade by the phenomenon of urbanization. More than half of the world’s population now lives in cities, and issues related to sustainable and equitable urbanization are high on the global agenda. Africa and Asia are projected to lead urban population growth in the next 4 decades. Since 1999, when the United Nations High Commissioner for Refugees (UNHCR) first began to disaggregate the number of refugees recorded as living in camps and rural and urban areas, the proportion of refugees residing in urban settings has been gradually increasing. For example, the cities of Damascus and Amman received more than 1 million refugees from Iraq, and other cities such as Nairobi, Cairo, Khartoum, Kabul, Abidjan, and Bogotá have absorbed millions of refugees and IDPs. However, capturing accurate data on displaced persons in urban areas is difficult. Many live in informal settlements and slums alongside rural-urban migrants and other poor and marginalized groups, beyond the radar of municipal authorities and aid agencies. Available data for refugees in 2011 show that the proportion of refugees 18 years and older is higher in urban settings (58%) than rural settings (46%) (UNHCR unpublished data). The profile of countries affected by conflict and displacement is gradually shifting toward a complex mix of developing countries and those with higher baseline incomes and life expectancies. For example, during the last 10 years, large-scale new displacements occurred in the Middle East, North Africa, and Latin America, alongside major refugee outflows and protracted crises in subSaharan Africa and Afghanistan. The urban displacement phenomenon has important consequences for international aid and protection agencies. In the health domain, 2 of the most important are management of noncommunicable diseases (NCDs) and health systems. The increasing global importance of NCDs was demonstrated with the 2011 UN General Assembly resolution on the prevention and control of noncommunicable diseases, which identified the socioeconomic scale of the problem and included an action-oriented declaration. However, the declaration does not address the importance and challenges of NCDs in conflict and forced displacement settings. During the past few years, UNHCR and its partners have modified their health information systems to include NCDs. For example, in 2010, of the 27 166 medical visits by 7642 Iraqi refugees in Jordan, chronic diseases were common, including hypertension (22%), visual disturbances (12%), joint disorders (11%), and type 2 diabetes mellitus (11%). The archetypal image of rows of tents stretching into the distance in refugee camps no longer captures (if indeed it ever did) the daily reality for many refugees, a substantial proportion of whom live in urban settings and have a demographic profile similar to those who live in middle-income countries. These older populations have disease profiles that are dominated by NCDs such as cardiovascular disorders, diabetes, and cancer rather than