COVID-19: Learning Lessons About Local Action From Past Outbreaks

I am relatively new to the world of urban policy and research. My background is in anthropology and I’ve been researching health systems and diseases for the last 10 years. I came to the urban space via the Ebola epidemic in West Africa. I’d been working in rural Sierra Leone on another viral haemorrhagic fever known as Lassa fever (Ebola and Lassa are both viral haemorrhagic fevers) which led me to become involved in the Ebola response there. One of the unprecedented things about that Ebola outbreak (there have been at least three since) was that it reached urban centres with the fear that it would be uncontrollable. I remember a meeting to discuss the control strategies where the people in charge admitted they did not know what to do if the disease reached ‘slums’ and informal settlements, areas of presumed chaos.

At that point, at least in the Ebola response public health community, urban settings were a mystery. While anthropologists had a good idea about health-seeking behaviour, burial practices, and social and power dynamics in rural communities, we did not have the same level of understanding for rapidly growing cities. I’ve been researching urban health and its connection to urban social and political life ever since. Of course, famously, Ebola did reach the poor neighbourhoods of Conakry, Monrovia, and Freetown. The initial responses were predictably inadequate, for example, the quarantining of a whole neighbourhood in Monrovia which resulted in riots.

The West African Ebola epidemic revealed at least four things about infectious diseases and informal urban settlements. First, the nightmare of rapid disease spread in dense cities with poor sanitation can come true. Second, knowledge of residents’ rationales, practices, and social organisation around health in informal urban settlements was inadequate, and as a result prevailing approaches to community engagement and intervention were insufficient. Third, compelling evidence emerged of local learning and collective action towards disease control. In Freetown, Monrovia, and Kenema (Eastern Sierra Leone) there was large-scale rapid learning and coordination across neighbourhoods. Neighbourhood task forces were formed, bylaws implemented, movement restrictions imposed, local groups carried out ‘house to house’ checks and surveillance, and in some cases home care. In some places, this was in conjunction with outside help, but sometimes it was independent of it. Models that predicted millions of deaths thankfully did not come true, and local action was a major factor in this. Fourth, and less positively, distrust between residents and outsiders was two-way and ran deep.

This trip down memory lane is fitting as we are once again faced with an infectious disease outbreak which feels uncontrollable, and once again there is particular concern about slums and informal urban settlements. There is heightened concern about these settings due to the combination of population density, limited infrastructure, and precarious livelihoods. While certainly true that informal settlements face acute challenges around the control of COVID-19, locally developed strategies could mitigate the worst of the outbreak if action is taken fast—and providing it is combined with adequate support from local government and other external agencies. Lessons from previous humanitarian and health crises, urban or otherwise, highlight that locally-led initiatives which take local priorities, concerns and, contexts into account are key to effectiveness and reducing harm. States of emergency and ‘emergency thinking’ can sometimes preclude bottom-up approaches but ultimately they will depend on them. In China’s unprecedented quarantine of Wuhan, neighbourhood-based groups were involved in ensuring movement control. Community-led initiatives are already spreading across the world.

Informal settlements have the potential to be highly organised, and often have a range of local groups and community structures who provide and advocate for services, and collect their own data on residential populations and facilities. These groups and systems are well-placed to mount COVID-19 responses and many already are. They are particularly well-placed to consider options in their area for decentralised forms of care, identification and protection of the vulnerable, and physical distancing strategies for the wider population.

There are activists and organizations who provide essential links to communities that have worked tirelessly to advocate and bring about change in informal urban settlements for decades. Partnerships with local authorities and support for local action will be essential. Financial and non-financial resources (e.g. information, equipment, rapid extension of basic services, and supportive policy-making) are urgently needed to enable local residents to develop and implement their own strategies. The mass movement of Indian migrant workers, and harrowing scenes from around the world, are a reminder that public health interventions must be balanced with social and economic interventions, especially concerning the informal economy on which most people depend. The vulnerabilities to COVID-19 are immense in informal settlements, but poorly executed control measures only amplify the deep negative impacts.

Finally, I’d like to return to the issue of trust. Historically, informal settlements and their residents have been stigmatised, blamed, and subject to rules and regulations which are unaffordable or unfeasible to adhere to. Responses to COVID-19 should not repeat these mistakes. Collaborating with local residents and trusting them as stewards of their community, with unsurpassed knowledge of relevant spatial and social infrastructures, will enable effective control measures and build trust in the longer term. And it must not stop when the pandemic stops. Epidemics have the potential to be ‘eye-openers’, revealing the stresses, anxieties, vulnerabilities, and inequalities less visible in ‘normal’ times. We are seeing this clearly now with COVID-19.

After the West African Ebola epidemic, there were many promises about ‘never again’ but ultimately there was minimal change to the lives of the urban poor in Freetown or Monrovia. Once again, they must face another disease without the protection of basic infrastructure and only their ‘resilience’. A post-COVID-19 world requires a much greater focus on these inequalities that have left people exposed and a commitment to inclusive urbanisation for all.
For more on key considerations and practical approaches to protecting informal settlements from COVID-19 please see this briefing on the subject by the Social Science and Humanitarian Action Platform.