How to tackle Covid-19 in informal settlements


How to tackle Covid-19 in informal settlements



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How to tackle Covid-19 in informal
settlements
Mark Weston 2/7 Mar 2020
In these environments, staying at home can itself be a risk. Cramped, often poorly ventilated dwellings housing
large numbers of people are potential petri dishes for Covid-19. (David Harrison/M&G)
Western governments, following the example of China, have adopted
broadly similar approaches to tackling the
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Lower-income countries are beginning to copy this model. Rwanda,
South Africa and India are on full lockdown, while Kenya and Sudan are
on partial lockdown. Measures implemented by other low-income
countries in Asia, Africa and Latin America grow stricter by the day.
A one-size-fits-all approach, however, risks overlooking the enormous
differences between rich and poor countries with regard to living

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conditions, social mores and the availability of resources and services.
In particular, the large number of low-income-country residents who live
in informal settlements, or slums, will be ill-served by measures that rely
on the stockpiling of food, the availability of savings, the ability to work
from home and the need to keep your distance even from close relatives.
In these environments, staying at home can itself be a risk. Cramped,
often poorly ventilated dwellings housing large numbers of people are
potential petri dishes for Covid-19. Queuing to use shared toilets or draw
water from wells or boreholes, using crowded public transport or simply
walking past others in narrow lanes heightens the risk of exposure.
If informal settlements are locked down and their inhabitants lose access
to work, food and other essentials, there will be a risk not only of the
coronavirus ravaging communities that contain large numbers of
Individuals who are vulnerable to its most serious effects, but also of
exacerbating malnutrition, increasing the risk of other diseases and
plunging millions of people into — or further into — long-term poverty.
Policymakers need tailored rather than uniform approaches to tackling
Covid-19 in informal settlements. Here are eight ideas for doing it
differently.
1. Adapt to the context
Just as measures that work to combat Covid-19 in high-income countries
will not necessarily be suitable for the developing world, so will blanket
measures covering all informal settlements likely be ineffective. A
Brazilian favela is very different to a slum in rural Tanzania. An informal
settlement in Ouagadougou Is different to a Turkish gecekondu or
refugee camp.
In rural areas, for example, residents of informal settlements will be better
able to implement social distancing measures to contain Covid-19 than
their urban counterparts. They will be better able to grow their own food

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in the event of a prolonged lockdown. Residents of urban slums, on the
other hand, may be protected from the virus to some extent by their
relative youthfulness and their higher education levels, although
vulnerable elderly residents of urban settlements may be more likely to
live alone and have weaker support networks than their rural cousins.
There are many other differences between informal settlements that will
affect the response to the virus. These relate to the physical
environment, the climate, population size, cultural and linguistic factors,
crime rates and the presence of gangs, the relationship with the state,
intergenerational relationships and so forth. Policies including resource
provision, educational messaging, and training and support for
community leaders will be effective only if they are adapted to the
characteristics of each settlement.
2. Test and tailor education messages
Educating the residents of informal settlements about how to avoid
infection, what to do if they are infected and how to care for the sick are
critical tasks in environments in which state-provided healthcare Is
largely or completely absent.
Education messages must be appropriate to their audience. They need to
speak their language (in urban slums in particular, residents often hail
from a number of different ethnic groups or countries and speak many
different languages), respond to their concerns, take account of available
resources, be distributed through media that slum residents use and
counter false information. To transmit messages effectively, moreover,
trusted messengers must be deployed, and their buy-in secured.
Although some messages — such as the value of regular handwashing —
are universally appropriate (at least where people can access soap) and
can be delivered immediately, others will need testing and refining over
time.

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For example, early messages about HIV/Aids in Africa so alarmed people
that they created enormous stigma around those people suspected of
having the virus. This made people more reluctant to present for testing
and helped the disease to spread more quickly. During Sierra Leone's
Ebola epidemic, researchers discovered that government health workers,
who in the early days had been charged with delivering prevention
education, were not trusted in many informal settlements. In Sudan,
myths about the coronavirus include the protective effect of mangoes,
ice cream and previous use of chloroquine for malaria treatment. In the
United States, President Donald Trump's claim that the virus was a hoax
has persuaded many people that they have nothing to fear.
Only research can show educators the level of existing knowledge in
different populations and help them to develop culturally appropriate
messages that will help to combat rather than aggravate the virus. And
only research can show them who is best placed to deliver resonant
messages in each context — and to different population groups in each
context.
3.Don't expect to eliminate risk
People living in informal settlements have much more contact with others
than those who live in formal settlements — research in Delhi found they
have 50% greater contact duration per day than non-slum residents.
Policies that aim to eliminate Covid-19 transmission will, therefore, need
to be so draconian that all other activities must cease. For households
that bring in only enough income each day to buy a day’s supply of food,
the risks of such confinement will be impossible to bear for long.
But although mass self-isolation may be undesirable, more limited
containment measures can help reduce transmission. Banning large
gatherings at weddings and funerals; persuading religious leaders to
postpone services, or at least to hold them outdoors or stagger them to
reduce attendance; closing video halls and bars (perhaps allowing the
latter to sell take-outs only); and educating people to stand as far as

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possible apart while queuing are obvious first steps.
Temporary measures to isolate cohorts of people — whereby individuals
group themselves into the smallest possible unit that can provide each
member with essential provisions and services — can also slow
transmission. In Europe the predominant cohort unit is the household,
but in informal settlements it might encompass a house, a compound, a
street, a block, or even a district or village.
Such cohort units could assign specific dwellings for those people at
high risk of Covid-19 infection (a measure Known as targeted
quarantining), people who are infected and in need of care, and people
who have to leave the unit to work. They could also develop rota systems
to reduce the number of members who go out to the market or to fetch
water, dispose of sewage, collect mobile payments or use public
transport.
The number of entry points to these units should be minimised — in
Brazil, gangs have placed soap by public water fountains at the entrance
to favelas, with signs urging those who enter to wash their hands —
and outdoor areas can be assigned for limited numbers of outsiders to
visit relatives inside the unit, as well as for unit meetings to be held. With
larger units, such as whole villages, travel between them should be
prohibited except in emergencies. Mobile food-distribution points can
serve those that struggle to sustain themselves. In both cases, when a
member falls sick the entire unit should self-isolate for 14 days, with
food, water and sewage services provided from outside.
4.Focus resources on the vulnerable
The governments of countries that have large slum populations are
generally strapped for resources. Targeting education messages, regular
testing, treatment and Isolation strategies at pregnant women, older
people (in slums, those aged over 60) and people with known or
suspected chronic underlying conditions is a more realistic approach

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than aiming to protect the entire community from the disease.
Families with more than one room or house, too, could be encouraged to
allocate a living area to high-risk household members before the virus
hits, and taught to use infection-control methods to prevent the entry
Into that area of the virus.
5. Enlist and support community leaders
Community leaders are best placed to advise on the appropriate isolation
units and on the measures and constraints that might be accepted by the
inhabitants of each informal settlement. This is particularly important in
slums where the state has limited legitimacy and capacity.
Such figures may include local chiefs or councillors, religious leaders,
medical and other professionals, businesspeople, traditional healers or
youth group leaders, and will vary depending on the settlement. Most
informal settlements have some form of community-based organisation
or residents’ association, and the acceptability of coronavirus control
measures will be greatly enhanced if they have these groups’ support.
Community leaders can play a role in disseminating education messages,
identifying and isolating suspected cases, enforcing rules such as social
distancing in queues and limited movement between units, and
distributing protective equipment such as masks, soaps and hand
Sanitisers.
They can also develop measures of their own, which may be more
appropriate to the local context than broad-based policies developed by
central governments. Sudan's Neighbourhood Resistance Committees,
which were instrumental in ousting the dictator Omar al-Bashir last year,
have been making and distributing hand sanitisers using alcohol originally
intended for use in illicit liquor. During Sierra Leone's Ebola epidemic,
groups of young men used plastic bags and rice sacks to make their own
personal protective equipment for conducting safe burials.

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But community groups should not be expected to go it alone. Local and
national governments, nongovernmental organisations, businesses,
diaspora groups and the international community must support them
with materials — soap and hand sanitisers, educational posters and
leaflets, testing equipment and so on; with basic services — free water,
waste disposal, food provision for people unable to feed themselves, and
mobile clinics to complement a slum’s existing health centres; and with
training to give them the knowledge and skills they need to identify those
most at risk of severe Covid-19, recognise symptoms, deliver
information, and organise the care and quarantining of people who fall
sick.
6. Don't forget human rights
In Rwanda and India, police have already killed citizens for breaking
curfew. Residents of informal settlements often have a troubled
relationship with state institutions and beating people to death for going
out to buy milk is unlikely to improve matters.
If populations are to comply with Covid-19 containment and prevention
measures, they will have to trust the people who are enforcing them.
Without trust — and if governments trample human rights in their efforts
to contain the disease — rules will be ignored and the virus will spread
more quickly.
Engaging community leaders to help implement and enforce the
response to the virus will ensure that rights are upheld. Regular
consultations with slum residents will apprise external actors of both their
concerns and their suggestions for fairer ways of implementing policies.
7. Empower the youth
Although young people in informal settlements are less vulnerable to
severe coronavirus than their elders, they will need support to maintain

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their livelihoods. Some governments, such as the state government of
Uttar Pradesh in India, can afford to pay people not to work, at least in
the short term. In Sudan, donations from the diaspora have been used by
the Sudanese Professionals Association, a trade union, to persuade
street vendors to stay at home.
Most governments in countries with large slum populations cannot afford
such policies. It may be cost-effective, however, to pay young people to
provide services during the epidemic. Youth underemployment Is rife in
many slums, and young people can be recruited to deliver provisions to
the sick or to self-isolating units, to police toilet and borehole queues, to
assist with waste disposal and water delivery, to transmit educational
messages to their peers, to impart lessons to children whose schools
have shut down and to perform many other tasks.
In this way, the virus can be an opportunity to unleash the potential of
young slum residents, giving them cash while the epidemic persists and
much-needed capital to set up their own businesses in Its wake. Their
entrepreneurialism and creativity should also be rewarded — those who
come up with new ways of tackling the virus and its effects should be
given cash rewards. Young women, too, will be empowered by such
Strategies and will devise new ideas of their own for use both during and
after the epidemic.
8. Don't forget long-term challenges
For the majority of people living in informal settlements, Covid-19 will be
far from the biggest health threat they have faced. It is important to
continue to provide services to prevent, detect and treat other
communicable and noncommunicable diseases, regardless of whether
they are aggravated by Covid-19 infection.
To reduce the burden on health services, the provision of non-essential
services could be postponed until the coronavirus epidemic has
subsided, while shuttered schools could be opened to treat people with

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minor health issues, to deliver childhood vaccination programmes, or to
attend to people with conditions that might be exacerbated by Covid-19
Infection. Opening more healthcare delivery points will also reduce the
footfall of people who may be infected with the virus (in some countries
there have been reports of crowds of people queuing outside hospitals
with suspected fevers, for example), thereby reducing transmission.
At the same time, residents of informal settlements have many other
long-term challenges to deal with, which risk being neglected if
resources are diverted to Covid-19 control. Cutting education budgets,
for example, would have serious long-term consequences — including
health consequences — for slum residents. Neglecting sanitation,
environmental, microfinance and other programmes will also pose grave
risks.
The coronavirus is one challenge among many for those living in the
world’s informal settlements. Balancing the response to it with broader
healthcare and other development priorities will be essential if their long-
term resilience to such threats is to be strengthened rather than
dismantled.
Mark Weston Is a writer, researcher and consultant working on
public health, justice, youth employability and other global issues.
He lived for two years in an informal settlement on Ukerewe Island in
Tanzania and lived in Sudan until last weekend.
This article was first published on Global Dashboard.