Western governments, following the example of China, have adopted broadly similar approaches to tackling the COVID-19 pandemic. After initial hesitation, and once infection rates and deaths have reached sufficiently alarming levels, they have enforced country-wide lockdowns.
Lower-income countries are beginning to copy this model. Rwanda, South Africa, and India are on full lockdown; Kenya and Sudan 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 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 heighten 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 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 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 on. Policies including resource provision, educational messaging, and training and support for community leaders will only be effective if they are adapted to the characteristics of each settlement.
2. Test and tailor education messages: Educating the residents of informal settlements on how to avoid infection, what to do if infected, and how to care for the sick are critical tasks in environments where 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, use media that slum residents use, and counter false information. To transmit messages effectively, moreover, trusted messengers must be deployed, and their buy-in secured.
While 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.
For example, early messages on HIV/AIDS in Africa so alarmed people that they created enormous stigma around those 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 around the coronavirus include the protective effect of mangoes, ice-cream, and previous use of chloroquine for malaria treatment, while Donald Trump’s claim that the virus was a hoax has persuaded many that they have nothing to fear.
Only research can show educators the level of existing knowledge in different populations and help them develop culturally-appropriate messages that will help 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 within 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, and for households that only bring in 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 while 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 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 at high risk of COVID-19 infection (a measure known as targeted quarantining), those who are infected and in need of care, and those 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 – while 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, while 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, the elderly (in slums, those aged over 60), and those with known or suspected chronic underlying conditions is a more realistic approach than aiming to protect the whole 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.
But community groups should not be expected to go it alone. Local and national governments, NGOs, 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 those 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 those who fall sick.
6. Don’t forget human rights: Coronavirus lockdowns in Rwanda and India have already seen citizens killed by the police for breaking curfews. 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 measures, they will have to trust those 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, while 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 less vulnerable than their elders to severe coronavirus, young people in informal settlements will need support to maintain 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 non-communicable diseases, regardless of whether they are aggravated by COVID-19.
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 up to treat people with minor health issues, to deliver childhood vaccination programmes, or to attend to those with conditions that might be exacerbated by COVID-19. Opening up more healthcare delivery points will also reduce the footfall of those 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.