Beyond Borders

Urban survivors
Humanitarian challenges of a rising slum population


In 2009, humanity crossed a profound threshold. For the first time, more than half of the world’s population lived in cities rather than in rural areas. Many people made the move seeking greater economic opportunity, but rapid and sustained urbanisation has swelled existing slums, and spurred the creation of new ones in countries around the world. More than 800 million people now live in slum conditions. That is more than one out of every 10 people on the planet. Through its work in urban settings throughout the developing world, MSF has first-hand experience of the impact that slum environments can have on public health.

Slum residents live in a state of constant vulnerability. Pervasive pollution and unhygienic living conditions breed diarrhoeal and respiratory diseases. Population density, the lack of proper sanitation, and the shortage of public health facilities mean that other communicable diseases – cholera, for instance – or severe weather can have devastating effects. Slum inhabitants often must adjust to a life of poverty in a place where there is more violence and more crime, where they are marginalised and discriminated against.


Although people in urban settings may live geographically closer to healthcare facilities, other factors complicate the process of delivering healthcare to urban populations. Streets might be too crowded and narrow for vehicles to pass through, and there can be unacceptable security risks. In Rio de Janeiro, for instance, MSF ran a project in one of the slums between August 2007 and April 2009, focusing on emergency stabilisation for victims of violence and referrals to second- and third-level structures. Due to the high rates of violence, teams first had to enter into lengthy negotiations in order to convince the local populations – and the local gangs – that MSF was neutral, impartial, and independent.

In MSF’s project in Johannesburg, staff have seen that many undocumented migrants choose to remain hidden or underground because of their lack of legal status. As a result, MSF has had to be more proactive in order to reach this population. Therefore, MSF teams conduct health promotion activities and general health screenings through mobile clinics at the slum buildings. Similarly, in Kamrangirchar, in Dhaka, many parents have to choose between going to work to earn a daily living or taking their children to the hospital; they cannot do both. MSF has responded by conducting home visits that bring care closer to the patients and in some cases organising transportation to and from the health centre.

Humanitarian crisis

MSF has been responding to urban health problems in a host of different ways – treating malnourished children in Dhaka, responding to cholera outbreaks and sexual violence in Port-au-Prince, and providing medical care to vulnerable migrant populations in central Johannesburg, to name just a few examples. Given the unplanned, unregulated, and largely uninterrupted flow of people into urban centres, there is an increasingly urgent need to recognise and understand the fact that slum residents are indeed facing a medical humanitarian crisis.

Slum inhabitants endure extreme living conditions on a daily basis. Many slum settlements are located close to or directly on top of former industrial sites, meaning that the residents are frequently exposed to toxic and chemical waste. There are often too few latrines – in some cases hundreds of families must share a very small number of them. Systems for drainage and waste disposal are substandard, if they exist at all, which leaves people ever more vulnerable to the spread of water-borne diseases such as cholera or diarrhoea.

Health problems

Children are particularly at risk of contracting an illness, or even dying. They tend to have more contact with contaminated soil and water than adults, and because of their low body weight they are more likely to suffer harm if they ingest toxins. In the Kamrangirchar slum of Dhaka in Bangladesh, 10% of all consultations at MSF’s clinics are for diarrhoeal diseases and skin infections – something which can be tied to undrinkable water, pollution, and unsanitary living conditions in this area.

In settings where people live packed closely together without access to safe drinking water, there are much higher risks of outbreaks of water-borne diseases. This is what happened in October 2010, when cholera began to spread in and around Haiti’s capital city, Port-au- Prince. MSF assessments showed that the rapid rise in the number of infections was linked to the fact that many people lacked access to clean drinking water and effective sanitation. MSF subsequently treated nearly 60,000 people in Port-au-Prince for cholera. Areas with poor sanitation and stagnant water are also ideal breeding grounds for mosquitoes carrying malaria and dengue.

People often cannot be separated from an infected family member or neighbour due to the cramped living areas. In these environments, special infection control measures need to be taken. In the Indian city of Mumbai, for example, MSF is installing fans and extra windows into the homes of tuberculosis patients in order to improve ventilation and protect their family members from contagion. Patients are also encouraged to wear protective masks at all times when they are around other people.

Resources needed

It is evident that slum environments can cause or exacerbate severe and widereaching health problems, and create particular challenges for women, children, and undocumented migrants. As cities will continue to expand, slums will expand with them. This is something we cannot ignore. Through its work in urban settings over the last decades, MSF has experienced how a growing urban population has created an increased need for humanitarian interventions in slum environments In many places, the situation is so grave that it cannot be described as anything less than a humanitarian emergency.

Subsequently, MSF has increased its resources to work in such settings and is now running projects in over 20 cities across the world. In these projects, MSF has had to adapt tools and procedures that were originally designed for rural areas, while taking into account local conditions and cultural traditions. A model that works in a rural clinic in South Sudan may work less effectively in the crowded alleyways of Mumbai or Port-au-Prince, and a program that is run in Kibera may need to be adapted if it is going to be replicated in Karachi.

MSF has had to develop partnerships with city authorities, local NGOs, and urban planners to create man environment in which programmes can be effectively implemented and managed, and in which health and hygiene can be promoted and encouraged. It has also been important to work with the local people themselves to give those often-neglected and disenfranchised.

Urban survivors is a multimedia project by Médecins Sans Frontières (MSF) in collaboration with the NOOR photo agency and Darjeeling Productions, which highlights the critical humanitarian and medical needs that exist in urban slums the world over. The interactive website,, takes the visitor on a virtual journey through five slums – in Dhaka, Karachi, Johannesburg, Portau-Prince and Nairobi – where MSF is actively running projects. Featuring the work of award-winning NOOR photographers Stanley Greene, Alixandra Fazzina, Francesco Zizola, Jon Lowenstein and Pep Bonet, Urban Survivors lets the visitor discover more about the daily lives of people in these slums, the humanitarian issues they face, and what MSF is doing to address these problems.

 Date of upload: 21st Jan 2012


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