By Rachel Tolhurst and Sally Theobald, based on presentations by JK Lakshmi, Sabina Rashid, Joseph Macarthy, Beate Ringwald, Caroline Kabaria and Lilian Otiso (Chair) (ARISE Hub)
There is a mismatch between ground realities for the urban poor and many national and municipal responses to the Covid-19 pandemic. In a session at the Sixth Global Symposium on Health Systems Research (HSR2020), ARISE presenters – from India, Bangladesh, Sierra Leone and Kenya – shared insights on how the pandemic is amplifying the vulnerabilities of marginalised people living and working in informal urban spaces.
Government responses to Covid-19 have tended to take a very biomedical approach, focusing on prevention messaging and movement restrictions. But these approaches rarely take into account the environmental and economic realities and existing privations of people living in informal settlements. These areas of cities in low- and middle-income countries are generally congested, with cramped, poor quality housing, and a lack of sufficient access to water and sanitation services.
While governments did provide some aid to basic needs, including food aid in India, and support to prevention such as buckets and soap in Sierra Leone, in most cases this was insufficient to meet needs and did not reach many, due to bureaucratic hurdles, corruption and mismanagement as well as the sheer scale of need. Some of the challenges that were noted included:
- Access to water and sanitation: In Sierra Leone, water access points became congested during lockdown. In Bangladesh people described having to choose between spending limited money on food or prevention measures such as water and soap.
- Access to money: People in the formal sector lost their jobs during lockdown and for many who are reliant on daily earnings in the informal sector, movement restrictions and curfews meant they could not meet their basic needs. People described hunger and adults talked about rationing their own food in order to feed their children.
- Access to food aid: Some waste-picking families in India described receiving only insufficient food, with no support for cooking gas, water or menstrual hygiene for example; others such as migrants were unable to access any support as their citizenship certificates (e.g. Adhar identify cards) were registered in another location. They understood the need for movement restrictions to reduce transmission but explained: ‘to stay home there should be support for the poor… in this situation, how will one live?’.
- Social support: The crisis fractured existing, vital networks of support; in Dhaka for example, neighbours were no longer able to lend money or provide food to each other.
- Mental health: In all contexts there were high levels of anxiety, stress and distress, exacerbating tensions and increasing intimate partner violence. One waste-picker in India described their situation as ‘unable to live, unable to die’ ( చావలేక బ్రతకలేక). Putting red flags on the doors of affected households in Dhaka, amplified fear of infection, leading to stigma and community mistrust.
- Access to health services: Access to healthcare for pre-existing and non-Covid related needs was disrupted across all the cities, with wide reaching negative impacts. People were scared to utilise health services due to infection risk and services also struggled to cope. Some turned to private providers, incurring greater costs, whilst in some cases costs of transport to reach public facilities increased. In Kenya, elderly people were less able to use services because they needed physical support to reach them.
Learning from failures in the Covid-19 response
During the Covid-19 pandemic many communities, such as in informal settlements in Freetown Sierra Leone, rallied together to support the most vulnerable through community kitchens, and to disseminate locally appropriate messages about Covid-19 prevention through trusted networks.
Presenters shared some key principles for responses during crises and shocks, such as Covid-19. All emphasised the critical importance of timely, disaggregated information from people living and working in informal settlements about their vulnerabilities, needs and priorities. Working with in addition to learning from these communities is critical to build on their existing capacities and strengths and to ‘co-produce’ appropriate support. An example of participatory research with community members on intimate partner violence in Korogocho informal settlement in Nairobi illustrated their interest and capacity to engage in developing locally relevant responses to existing challenges that have been worsened during the pandemic.
There is a need for innovative and responsive research methods – including photovoice, social mapping and repeat phone interviews that build trust and support partnership. There was a call for the critical reflections on how governments and civil society organisations, including international agencies, can address structural deprivations and provide systemic and multisectoral support.
Covid-19 has shone a spotlight on the growing inequities experienced by people living and working within informal settlements, who are too often rendered invisible by official statistics. Re-imagining health systems for better health and social justice requires bold, multisectoral, context-specific and responsive approaches.
Image credit: Joseph Macarthy, Sierra Leone Research Centre