Health Disparities in Fragile, Humanitarian and Climate-Vulnerable Settings
When conflict, displacement and climate stress converge, mothers and children are the most vulnerable — and the data to protect them are weakest where they are needed most. We build the evidence to count everyone, and work — from complex health systems to refugee clinics — to find solutions that can reach them.
Summary
A growing share of the world's maternal and child deaths now occurs where conflict, displacement and climate stress converge. We follow the health of women and children along the full pathway of crisis: in conflict-affected and fragile settings, through displacement and transition, and into countries of resettlement, across environments where the climate is changing and disasters are unfolding.Our work starts from measurement, asking the questions that conventional approaches answer too slowly, or not at all: how far a woman in labour is from receiving care and how that shapes her chances of survival, and what her education, migrant status, ethnicity and economic status add to that distance; what exposure to war does to the babies of women who survive it, even after they have reached safety; and how a changing climate is reshaping the risks mothers and children face in strained, low-resource health systems.In each setting we examine, our focus is two-fold: disparities — who is hit hardest, who is reached last and who is left behind — and resilience — why some health systems, facilities and communities keep going under pressures that overwhelm others, what sustains them, and how that knowledge can be shared.
The portfolio is co-led by Dr Marwa Ramadan who works with Dr Siti Noraida Habibullah (School of Medicine), and is grounded in practice as well as scholarship. Dr Ramadan is a physician-epidemiologist with research collaborations and engagement spanning multilateral organisations and humanitarian agencies across more than 40 countries. Her work uses big data analytics to triangulate sources that rarely speak to each other, answering questions none of them can answer alone. Dr Siti Noraida is a Senior Lecturer at the Jeffrey Cheah School of Medicine and Health Sciences and a medical doctor with more than 25 years in clinical practice and healthcare leadership. Through Little Steps, the charity she founded, she runs Klinik Amal Muhajir — a charity medical and dental clinic serving refugees and asylum seekers in Klang — and a Cambodia Friendship Clinic for the poor, with a maternity home for vulnerable women under development in Kuala Lumpur; her humanitarian work has been recognised internationally, including with the Julia Taft Refugee Grant Award.
Our work is organised around three connected themes, built on frontline humanitarian practice and evidence-based measurement methods and tools for crisis settings.
Geospatial access to lifesaving care — and the inequities layered onto distance. Distance kills, but crudely measured distance misleads, and geography never acts alone. We generate and synthesise the evidence on how far people in low-resource, fragile and displacement settings really are from care, who is furthest, and what it costs in survival. Our work has contributed to shaping the new WHO norms on travel time to healthcare facilities in low- and middle-income countries.
Key outputs:
Roder-DeWan S, Ramadan M, Ouma P, Manu A, Okiro EA, Strobel N, et al. Impact of travel time to health facilities on perinatal outcomes: a systematic review with narrative synthesis and meta-analysis. Journal of Global Health, 2026;16:04136.
Ramadan M, Tappis H, Villar Uribe M, Brieger W. Access to primary healthcare services in conflict-affected fragile states: a subnational descriptive analysis of educational and wealth disparities in Cameroon, Democratic Republic of Congo, Mali, and Nigeria. International Journal for Equity in Health, 2021;20:253. doi:10.1186/s12939-021-01595-z
Conflict, displacement and the intergenerational reach of crisis. War does not end at the border, and its health effects do not end with the generation that flees. Our research on the perinatal outcomes of refugee and immigrant women shows how the circumstances people leave behind continue to shape the health of their children — and challenges receiving-country health systems to see displaced women not as a homogeneous category but as carriers of very different histories of exposure.
Key outputs:
Ramadan M, Shapiro GD, Yang S, Ng E, Vissandjée B, Vang ZM. Comparative analysis of perinatal health outcomes among refugee subgroups and economic immigrants in Canada (2000–2017). PLOS ONE, 2025;20(4):e0321453.
Ramadan M, Rukh-E-Qamar H, Yang S, Vang ZM. Fifty years of evidence on perinatal experience among refugee and asylum-seeking women in OECD countries: a scoping review. PLOS ONE, 2023;18(10):e0287617.
Tappis H, Ramadan M, Vargas J, Kahi V, Hering H, Schulte-Hillen C, et al. Neonatal mortality burden and trends in UNHCR refugee camps, 2006–2017: a retrospective analysis. BMC Public Health, 2021;21:390.
Ramadan MM, MSF-OCB Sexual Violence Care Study Group. Too many barriers: associations between the setup of sexual violence care programmes and access for male victims. F1000Research, 2017;6:905.
Lawrence O. Gostin, Neil R. Sircar, & Eric A. Friedman, Fighting Novel Diseases Amidst Humanitarian Crises, Hastings Center Report (January-February, 2019). DOI: 10.1002/hast.970
Measuring health systems and humanitarian action. In crisis settings, the hardest things to measure are the quality of care and the results of humanitarian response itself — and they are also the things most worth measuring. We develop and apply measurement approaches for health system performance in fragile settings, using population and facility surveys to expose the gaps that coverage statistics conceal.
Key outputs:
Altare C, Weiss W, Ramadan M, Tappis H, Spiegel PB. Measuring results of humanitarian action: adapting public health indicators to different contexts. Conflict and Health, 2022;16:54.
Ramadan M, Tappis H, Brieger W. Primary healthcare quality in conflict and fragility: a subnational analysis of disparities using population health surveys. Conflict and Health, 2022;16:36.
Ramadan M, Muthee TB, Okara L, Feil C, Villar Uribe M. Existing gaps and missed opportunities in delivering quality nutrition services in primary healthcare: a descriptive analysis of patient experience and provider competence. BMJ Open, 2023;13(2):e064819.
Ramadan M, Gutierrez JC, Feil C, Bolongaita S, Bernal O, Villar Uribe M. Capacity and quality of maternal and child health services delivery at the subnational primary healthcare level in relation to intermediate health outputs. BMJ Open, 2023;13(1):e065223.
Ongoing projects
Antenatal care and outcomes among local and refugee communities in Malaysia — a single-centre comparative study of disparities in care and outcomes.
Moral distress and wellbeing of health workers delivering refugee care — examining the ethical challenges facing providers who care for refugees and asylum seekers in Malaysia.
Faith, solidarity and the obligations of care — drawing on Islamic ethics and ideas of justice to ask how faith shapes solidarity with refugees, including in Malaysian refugee policy. Recent outputs include a book chapter on Islamic ethics and the spiritual development of children (Routledge, 2026) and conference papers on the limits of religious solidarity in Malaysian refugee policy and on Islamic ethics perspectives on social justice and health disparities.
Climate vulnerability and community health — restructuring longitudinal data from the South East Asia Community Observatory (SEACO) to examine the relationship between community health and climate vulnerability in Segamat, Johor.
Large language models for evidence synthesis in crisis settings — piloting the use of language models to accelerate evidence reviews and the analysis of routine reports and documents, where the pace of crisis outstrips the pace of conventional synthesis.
Administrative data for child malnutrition estimation — a scoping review of the use of administrative data in estimating child malnutrition, linked to the UNICEF–WHO–World Bank Joint Malnutrition Estimates (JME) methods agenda.
The lagged effects of armed conflict — examining the impact of premigration conflict exposure on perinatal outcomes among immigrant populations in Canada.
Health inequities in Malaysia — contribution to the Marmot Review health inequities project in Malaysia.
Our portfolio is deeply embedded in operational research and the humanitarian–development nexus, through active collaboration with organisations including the World Bank Group, WHO, UNICEF and UNHCR, and local and regional partners such as MRA and IMARET. We share knowledge that supports governments' decision-making in the most crisis-affected settings — from health financing and results frameworks to facility-level assessments of service delivery and epidemic preparedness — and we provide frontline care to migrant and refugee communities where access to services is most constrained. We also bring this work to national and regional platforms, from Malaysia's Ministry of Health congress on maternal death enquiries, where our team has presented on humanitarian obstetrics, to regional forums on refugee studies, bioethics and health law. What we learn in operations and in the clinic flows back to shape the questions we ask.
Most research on displaced and underserved populations is done far from the people it describes. Ours is anchored in the communities themselves, through two complementary platforms. The first is clinical. Malaysia hosts one of the region's largest urban refugee populations, much of whose healthcare is delivered by faith-based and charitable providers — a reality that is central to how care actually reaches displaced people in this region, yet largely absent from the global evidence. Through Klinik Amal Muhajir and the planned maternity home, our evidence on displaced women's health meets the daily reality of delivering that care, each shaping the other; the clinics work with specialists through collaborations with Universiti Malaya, Universiti Kebangsaan Malaysia and Universiti Putra Malaysia. The second is population-based. SEACO, Monash's health and demographic surveillance site in Segamat, Johor, follows a settled, semi-rural Malaysian community over time through a longitudinal, geocoded platform. It anchors our work on climate vulnerability and community health, and demonstrates what continuous, high-quality population data make possible for communities and policy. Together, the clinics and the observatory allow the portfolio to study both displaced and settled populations facing converging risks — and keep the research close to the people it is meant to serve. We also help set the agenda at home: in 2026 the portfolio chaired the Migration Health Ethics Workshop at Monash University Malaysia, convening researchers and practitioners around social justice for forced migrants in Malaysia.
Topic co-leads: Dr Marwa Ramadan and Dr Siti Noraida Habibullah (School of Medicine)
Focus: Refugee and migrant health; fragile, conflict-affected and climate-vulnerable settings globally
Engagement: World Bank Group; UNICEF–WHO–World Bank Joint Malnutrition Estimates (JME) group; UNHCR; MRA and IMARET; Taylor’s University, Universiti Malaya, Universiti Kebangsaan Malaysia and Universiti Putra Malaysia