As part of Covid-19 guidance, governments around the world have advised people to wash their hands and stay at home. But what if your closest clean water supply is outside your home, in a public location?

This is just one of the challenges facing inhabitants of informal settlements, highlighted in new research conducted by Annie Wilkinson, a researcher at the Institute of Development Studies (IDS) into the impacts of Covid-19. To effectively combat both Covid-19 and future public health crises, policymakers should improve data collection in informal settlements, collaborate with local residents, and strengthen cooperation with local governments.

Informal settlements, or ‘slums’, are urban areas where housing structures don’t comply with government building regulations. Residents often squat or rent informally. Usually, these areas are a result of a lack of affordable housing, economic insecurity, and high migration — meaning that inhabitants are especially vulnerable to health risks such as Covid-19.

In many countries, government guidelines have prioritised the importance of both isolation and handwashing. The WHO has advised people to avoid crowded places. But as the recent paper published in peer-reviewed journal Environment and Urbanisation points out, these guidelines are not applicable to the more than 1 billion people who live in these areas.

The research, developed by IDS and the Sierra Leone Urban Research Centre (SLURC) as part of a research project on post-Ebola urban health in Sierra Leone, highlights the potential effects of Covid-19 and insights that should shape the response.

The vulnerabilities of informal settlements

The research points out that most Covid-19 recommendations assume people have a basic living standard — for example, access to running water for handwashing. But this assumption is incorrect, and a one-size-fits-all coronavirus response won’t work in informal settlements with unique epidemiological and transmission vulnerabilities.

Informal urban settlements tend to have high population densities and housing densities, making effective physical and social distancing difficult. Household structures are flexible, with people moving between homes to sleep, prepare food, or provide childcare. As increased mobility is an integral feature of most informal settlements, any instruction to “stay at home” will most likely fail, argued the paper.

Residents of these settlements also experience limited access to clean water, prohibiting frequent handwashing. The paper identified water supply as an area of high risk — not only is it scarce and often expensive but communal water pickup points could be sites of transmission while people wait in queues.

Self-isolation is almost impossible in homes without basic services. Residents need to leave to retrieve food and water for basic sanitation and hygiene needs and to participate in both social and economic networks. Most people living informal settlements are less able to store food, and banning movement could prevent them from purchasing clean water and food, potentially worsening pre-existing health inequalities.

A Covid-19 response that doesn’t take these features of informal settlements into account runs the risk of being not only ineffective but also harmful, the research warned. To accurately capture the unique vulnerabilities of each settlement, response planners need access to relevant and up-to-date data.

The need for community-driven data

Crisis planners depend on epidemiological models to predict the spread of Covid-19, and these models need information on the population in question to function. Those responding to the crisis in informal settlements have the same need for data to accurately measure infections and the effect of control measures.

The nature of informal settlements makes this data difficult to collect — the population is highly transient, often wary of government and in many cases has legal reasons to avoid being monitored.

However, the author points to community-based groups as one solution to this problem. For example, SDI, a network of such organisations spanning 32 countries, collects community-driven data on urban slums. By working with local inhabitants, SDI gathers crucial information such as the cost of water, the estimated number of structures and access to healthcare.

This data is useful for local governments and other responders. In Sierra Leone, SDI has coordinated with the Freetown City Council and other local organisations to create a Covid-19 response appropriate to the needs of the Freetown informal settlement. But no two informal settlements are the same, and pandemic measures that work best in one area might be ineffective in another. Policymakers and health planners should aim to understand the unique features of a local settlement by increasing community engagement.

Creating a locally appropriate response

Understanding how health systems operate within informal settlements will be vital to creating a targeted Covid-19 response. While much of the global conversation has focussed on hospital capacity, sick people in informal settlements are unlikely to visit hospitals in the first place. Instead, many rely on informal health providers or community advisers for health advice and visit pop-up pharmacies for treatments.

These local providers will know the most about community health. Travelling health workers are at risk of spreading infection, but will also have the most up-to-date information on where people are getting sick. Barriers to formal healthcare make it more likely that cases spread undetected, so crisis responders must engage with these community health carers to successfully track infections.

Creating a locally appropriate response also means disseminating health information from a trusted source. Despite being historically characterised as disorganised, informal settlements often have complex and organised social structures. Trusted leaders are unlikely to be connected to the government and could be anyone from a business person, religious leader, or councillor. Any effective response messaging will need to to be coordinated with these local leaders.

The paper highlights an “urgent need to support the development of locally-appropriate approaches to protect these populations from the worst impacts of Covid-19,” urging crisis planners to take three key actions:

  • Improve data collection in informal settlements
  • Collaborate with local residents with “unsurpassed knowledge of relevant spatial and social infrastructure”
  • Strengthen cooperation with local government

These insights should shape short-term efforts to combat the spread of Covid-19, but they also illustrate a larger need for change in urban planning and development. To improve public health, policymakers should prioritise effective health infrastructure in informal settlements, as well as invest in basic services such as water, sanitation and electricity. As the research shows, this development must be done in collaboration with community leaders and with local knowledge to be effective. — Ali Hunter

(Picture credit: Unsplash)