“Care is nowhere but everywhere”: Improvising care in medical precarity in urban Somali refugee community in Kenya

Urban Somali refugees in Nairobi, Kenya, navigate healthcare within a landscape defined by chronic insecurity, fragmented governance, and racialized exclusion. This ethnographic study examines how Somali refugees in Eastleigh experience and respond to medical precarity, understood as a structurally produced condition where formal health institutions are present yet inaccessible. Drawing on key informant interviews and focus group discussions with 98 refugees, health workers, and community leaders, alongside field observations conducted between 2018 and 2019, the analysis shows how care is deferred, avoided, and reassembled under conditions of economic constraint, legal risk, and institutional mistrust. Rather than withdrawing from care altogether, participants navigated illness through relational infrastructures that include pharmacies, household networks, and trusted intermediaries providing credit, advice, and continuity. These practices make care possible while also exposing refugees to exploitation and uneven quality in poorly regulated pharmaceutical markets. Participants also articulated a moral horizon of health shaped by aspirations for dignified treatment and transnational imaginaries of functioning health systems. The findings show that improvised care is not an informal deviation but a rational and ethical response to structural neglect. Medical precarity, in this context, does not merely constrain care; it reorganizes care through relational infrastructures and a pastoralist logic of medical seeking, characterized by continual recalibration of trust, cost, safety, and recognition across fragmented health systems. Yet these practices cannot fully resolve the health capability gap between knowing what care requires and having the conditions to make such care possible.