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Elika Dadsetan, Social Development Specialist, International Health and Epidemiology Research Center (IHERC), Director of Programs The World Health Organization states: “There is no health without mental health,” which means that in terms of achieving healthy cities, mental health and other supplementary support elements are key. There are many factors for city planners, architects and others to contemplate regarding what a “mentally healthy” environment can look like and how to deliver it, and social-cultural, physical-built, and economic environments all come into play. These factors become particularly important in the context of supporting the mental health of refugees in the city. Mental illnesses are on the rise, and we know that at least one in four people will experience some mental illness in their lives. These numbers are only magnified in communities experiencing distress across the board, such as refugees coming out of Syria. Although it is too soon to discuss impacts of these recent refugee crises, it is very likely that with the highest number of migrants in our modern history, we will see further increases in mental illness in these populations. Due to the stigma and misconceptions around mental illness, people often do not receive adequate medical care. In low and middle-income countries, approximately 80% of people living with mental illness receive no mental health treatment at all, or they use traditional healers that may not deliver effective care. This means they have fewer opportunity to achieve good health, reducing their chances to become involved in projects that may be able to help them out of poverty, or at least be able to afford the health care they require, creating a further vicious circle of poverty and mental illness. Thus, we cannot ignore mental health as a key determinant of health in urban contexts. We have to include mental health as part of the discussions about how we can encourage “healthy cities” for the sake of children and adults alike. Taking into consideration what types of positive support systems are needed for refugee populations, and others living in poverty, is key to “city” planning. Children's mental health can be particularly impacted by growing up in slums and refugee camps. First, we know that poverty is inextricably linked with mental illness, and can create and maintain a vicious cycle. People who live in urban poverty are at particular risk of mental illness, and those who are mentally ill are at a greater risk of social discrimination and exclusion; without healthy support systems, these people are more likely to experience extreme poverty.  Syrian refugee siblings in front of their tent. In the background there’s a photo of a fancy house- the boy explained that this is their dream house. Photograph by Ralph Baydoun, World Vision Lebanon. Living in cities increases the risk of developing certain mental illnesses, and for refugees living in urban poverty, these risks are often exacerbated because their living environments are often inherently stressful. For example, we know that children may have increased exposure to domestic and sexual violence, they may be more likely to worry about economic hardships, including child labor and child marriage, and children in these settings may experience greater levels of neglect or lack of parental engagement, since parents often have to spend time away from the home to earn money. We also see greater social isolation in urban slums, including refugee camps - both informal tented settlements or otherwise, and as such, increased risks for children to become involved in substance abuse, violence, sexual exploitation, and other risky behaviors and experiences. Furthermore, these children's adult caregivers are also at increased risk of developing mental illnesses - and this is a further risk factor for children's mental health. We know that suicide is amongst the top three causes of death for those of child-bearing age (15-44 year olds). The old “village” life that refugee children may be used to - and the care associated with it - may not be as prominent in their new lives.  Pictures of Syrian refugees during winter season in Lebanon. Photograph by Ralph Baydoun, World Vision Lebanon. Stress is, of course, a normal brain response to threat - but when it occurs constantly, stress can cause the structure of the brain to change. Research has shown that the amygdala (an area of the brain that regulates emotions like anxiety and fear) shows higher activation levels in healthy individuals living in large cities than in healthy counterparts living in rural regions. Our brains start developing before we are born and continue up through the age of 23 or 24, so consistent stress associated with living in urban areas may literally alter young people's brain structure, which may lead to increased stress levels, anxiety, life-long hyperactivity, and greater vulnerability to various adult mental illnesses. Children with higher stress or childhood disorders are also less likely to do well at school, which affects their education and work opportunities. This challenge is magnified for refugee children, at least half of whom are out of school (at least 3.4 million refugee children), which causes further challenges, particularly when they are required to work instead, or get married at a young age. Strategies for designing living environments that promote good mental health for refugees Creating safer public spaces through rebuilding community social networks, strategically improving the built environment, and securing economic opportunities can help change the narrative and help develop resiliency and rebuild the dignity of refugees' communities. The social/community environment When planning the design of living environments for refugees, there needs to be consideration around building capacity (human resources and otherwise) within the communities to capture the needs of individuals with distress. Utilizing experts and leadership from the community to develop strategies that are culturally relevant, appropriate, and effective, needs to be considered. Taking cultural contexts into consideration to ensure appropriate spaces is key. Organizing and promoting regular positive community activities, while providing a voice of power to the community, can help rebuild community social networks, and help redefine the narratives associated with the community. Communities also need to be able to restore a connection to their home countries, and help rebuild a sense of cultural identity, which has been shown to have a positive impact on mental health outcomes. Some of the most successful youth development, violence prevention, and health promotion programs build on existing community assets, and are dependent on community members and organizations that connect individuals to a supportive community. In communities where organizational infrastructure and capacity is lacking or absent, violence and trauma have a more profound impact on individuals and communities. Thus, more effort needs to be made to create social cohesion between the host communities and refugee communities, assuming the host communities have that missing capacity. Churches and spiritual leaders can fulfill some of these roles in many communities, but a healthy community has multiple entry points, including businesses, civic organizations, social organizations, schools, and youth-driven organizations that can contribute to the social and cultural environment that promotes positive relationships, social norms, behaviors, and activities within a community. The physical/built environment Reducing deterioration, and creating space for positive interaction are the most important physical/built environment priorities to support mental health. This may include reclaiming public space to be appealing to residents, reflect their community culture, and become a source of pride that can contribute to a sense of community worth and be supportive of healing. The systematic disinvestment and neglect of poor inner city communities has been a part of the structural violence that has produced community trauma over the last half century in the US, and other western societies. This is only exacerbated in communities that are hosting refugees. Thus, there is a need to focus on improving and maintaining roads, buildings, parks, transportation, and other public services so that they are transformed from sources of toxic stress, into an environment that encourages positive social interaction and relationships. A great example of such an attempt is in Colombia with the various social development projects set up in Medellin. Additionally, parks, playgrounds, and other recreational facilities provide critical opportunities for engaging in physical activity and gathering with neighbors, and especially in order to relieve stress. Their absence undermines community health, mental health and quality of life. Thus, these facilities not only normalizes daily life in the communities, but can serve as safe spaces for youth to gather and socialize, while engaging in physical activity. The economic environment Lastly, strategies to improve economic opportunities for youth and adults in these neighborhoods are critical to the success of healing from community trauma, improving community health and wellness, and resisting the pressures of additional dislocation. Actual workforce development strategies that improve employment skills, capacity, and readiness of community members, while linking them to job opportunities with a living wage is critical. This also helps avoid idle youth in refugee camps being recruited for armed forces, early marriage, or child labor activities. These strategies must be multi-sectoral, focusing on different segments of communities, including strategies to increase the proportion of young people and adults who attend primary, secondary and tertiary (including vocational) education, and undertake job training and placement. Planners must ensure that the infrastructure for people to access these opportunities is available. It would be helpful to institute restorative justice programs that shift the norms around conflict resolution and healing circles to, amongst other outcomes, support people to stay on paths to pursue educational and economic opportunities  Syrian refugees creating their own comfort zones. Photograph by Ralph Baydoun, World Vision Lebanon. What would help Mental health is not always talked about and fully documented in refugee populations; we need more documentation of the extent of the challenge, and more research on the most effective interventions. But for urban planners and designers, there is a need for increased capacity to recognize the needs of these populations: planning consultations with the communities are important - and should include people with mental health problems, and mental health and wellbeing promotion (including opportunities for play) should be actively built into future developments. About the Author
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