Key Considerations: COVID-19 in Informal Urban Settlements

"States of emergency and 'emergency thinking' can sometime preclude bottom-up approaches but ultimately they will depend on them."

A defining challenge of informal settlements and slums is the lack of data about them prior to, and during, emergencies. In the context of the COVID-19 pandemic, assessing acute and chronic vulnerability in low- and middle-income countries (LMICs) is challenging not only due to this lack of data but also to the novel nature of the virus. Drawing in part on experiences from the Ebola outbreak, this brief from the Science in Humanitarian Action Platform (SSHAP) discusses what is known about the vulnerabilities of the 1 billion people who live in informal settlements, sets out key considerations for protecting them from the spread and impacts of COVID-19, and explores how to use community engagement strategies to support local action among them.

At the time of writing, most COVID-19 cases had been detected in high-income countries, as well as in middle-income Iran. Concerns about the potential burden of COVID-19 in LMICs include:

• Epidemiological vulnerability (e.g., relevant chronic conditions, often undetected and poorly managed in LMICs, that could put large numbers of people at risk);
• Transmission vulnerability (e.g., population density and inadequate access to water and sanitation that make advice about social distancing and washing hands implausible);
• Health system vulnerability (e.g., established norms that prioritise work and daily survival (particularly given the mild onset of COVID-19 and messaging that there is no cure) and that may include visiting multiple informal providers instead of formal government clinics); and
• Vulnerability to control measures, including social protection failures (e.g., among children who relied on schools for meals (closed for COVID-19), or among isolated elderly populations in informal settlements who have no children or who are suffering abandonment).

Expanding on the final point above about control measures, some communication-related considerations related to stigma include:

• People or groups who have contracted COVID-19 or who become associated with it may experience stigma; messages about "social distancing" could exacerbate this and even extend to a settlement as a whole if the area and people within it become associated with disease spread.
• "Stigma often follows existing forms of social marginalisation and can have serious impacts (e.g., being asked to leave accommodation, losing jobs) and long term consequences for integration and participation in social and economic life."
• Historically, informal settlements and their residents have been stigmatised and blamed - externally applied images of "slums" may depict them as a social, environmental and developmental threat to the rest of the city - and they may have been subject to rules and regulations that are unaffordable or unfeasible to adhere to. "Responses to COVID-19 should not repeat these mistakes."
• "In settings where rationing and ill-equipped health services are the norm, people are not used to their health being considered a priority. Sudden interest in particular diseases or standards of public health can arouse suspicion." This can result in mistrust in government messaging and tension around the ethics and impacts of control measures. In short, "It is important to understand community power dynamics and political histories in a given settlement."

Other systemic vulnerabilities explored in the brief are related to: care networks; people with disabilities; displaced people; gendered impacts; safety and security; mental health; and evictions.

SSHAP stresses: "The organisational challenge of epidemic control is always intensive and dependent on meaningful local involvement." In that vein, the brief discusses approaches to local action, local data, partnerships, and support in LMICs. For example:

• There can be a high level of local organisation within informal settlements (e.g., community health worker networks); "It is crucial that responses to COVID-19 are organised through these groups and leaders who know their settings best and have existing links to residents."
• In light of the physical distancing imperative, community organisation processes that usually happen in-person and with the involvement of community elders may not be safe. Existing WhatsApp or Facebook groups (e.g., neighbourhood based) can be a channel for mobilisation, and radio is an important tool for communication. The key will be to manage misinformation and rumours that can cause confusion, distrust, or panic.
• Externally imposed restrictions "are likely to curtail survival in informal settlements more acutely and so run the risk of resistance and unrest unless developed with local participation, or allowing for local adaptation." The brief outlines potential options and issues, including:
  • Local taskforces/committees comprised of local leaders and community representatives can determine strategies for home care, self-isolation, movement controls (within and outside the settlement), closure of high-risk public spaces, support to vulnerable people, and communication. For instance, local groups could develop simple signage systems for homes that are self-isolating and/or require support. Suggestion: Establish focal points for case identification and reporting, social protection, general information, etc.
  • Use of interactive communication technology can enable physical distancing, though special efforts are required to communicate with vulnerable groups who may be less well connected/online. Religious leaders can use radio and social media to create alternatives to mass religious gatherings and to facilitate the safe provision of spiritual assistance. Suggestion: Publicise (on TV, radio, social media, and in print media, flyers) different communication channels and groups, giving information on how to join them.
  • Specific guidance is needed for people who provide essential services (e.g., garbage collectors), and protective equipment should be provided to these groups. Suggestion: Draw on local unions (formal and informal) to support the response to COVID-19 (e.g., garment factories sewing protective masks and equipment).
  • SSHAP notes: "Plans should be made with local communities about how an increase in the number of deaths will be managed." Suggestion: Consult with local populations to devise approaches that enable a chance to say goodbye and that allow social and spiritual rites to be performed (or safe adaptations of these - e.g., not touching but viewing the body). "Not doing this will increase individual and collective trauma..."

The brief goes on to list and explore the kinds of data needed for planning COVID-19 responses in informal settlements. For example, with the wider coverage of mobile phones in many urban areas, tools such as Facebook and Twitter can capture crisis alerts from communities and facilitate timely response during emergencies. Open source tools exist to allow communities to map themselves, complemented by online crowd-sourced mapping. Increasingly, SSHAP notes, there are online networks (e.g., delivery drivers) who have good local knowledge and who generate smartphone-based data, such as social data and knowledge analysing social networks, behaviour, and culture that could influence COVID-19 transmission. A theme running through all the data collection issues explored here is importance of connecting and supporting local efforts. For example, the approaches of SDI (Slum/Shack Dwellers International) have been used to engage with local community structures, leaders, and authorities to support responses to emergencies. A number of international networks exist that connect governments and agencies with local and community-based groups.

A list of illustrative related urban resources (e.g., mapping initiatives), with links, concludes the resource. These can support communicators who are are aware that, in informal settlements, clear information and advice about COVID-19 is needed. "People should be informed about COVID-19, how it is different from other diseases, and why the response asked of them for COVID-19 may be different. This is required to establish trust and mutual understanding given that extraordinary measures are not normally taken for the other fatal infectious diseases they live with."