Health systems in the world’s megacities and crowded urban settlements are about to be put under enormous strain as the new coronavirus takes hold, with the estimated 1.2 billion people who live in informal slums and shanty-towns at particular risk.
At a glance: Coronavirus and the urban poor
- The coronavirus is revealing the breadth of economic and social inequalities. Roughly 1.2 billion people live in informal settlements.
- There has not been major investment in preparing megacities cities for pandemics.
- COVID-19’s most significant threat may be from the political and economic fallout.
- Rapid urbanisation has shifted the front lines of many crises to cities, rather than rural areas. Aid groups have been slow to adjust.
- Urban aid requires major changes in how international groups operate: there will be less emphasis on direct delivery and more emphasis on partnerships.
- In some cases, aid groups may need to work alongside armed groups.
To understand more about the crisis confronting the urban poor, The New Humanitarian interviewed Robert Muggah, principal of The SecDev Group and co-founder of the Igarapé Institute, a think tank focused on urban innovation that has worked with the World Health Organisation to map pandemic threats and is supporting governments, businesses, and civil society groups to improve COVID-19 detection, response, and recovery.
What has so far been a public healthcare crisis in mostly wealthier cities in East Asia, Europe, and the United States appears likely to become an even graver disaster for countries with far less resources in Latin America, Africa, and South Asia.
Cities from Lagos to Mumbai to Rio de Janeiro have started locking down, but for residents of crowded slums the unenviable choice is often between a greater risk of catching and spreading disease or the certainty of hunger. Social distancing, self-isolation – handwashing even – are impossible luxuries.
This interview, conducted by email on 29-30 March, has been edited for length and clarity.
TNH: A lot has been made about the risks of coronavirus in crowded refugee and displacement camps – from Greece to Idlib. Do you feel the urban poor have been a little neglected?
Robert Muggah: While all populations are affected by the COVID-19 pandemic, not all populations are affected equally. Lower-income households and elderly individuals with underlying health conditions are particularly at-risk. Among the most vulnerable categories are the homeless, migrants, refugees, and displaced people. In some US cities, for example, undocumented migrants are fearful of being tested or going to the hospital for fear of forcible detainment, separation from their families, and deportation. In densely populated informal settlements and displaced person camps, there is a higher likelihood of infection because of the difficulties of social distancing. The limited testing, detection, isolation, and hospitalisation capacities in these settings mean we can expect a much higher rate of direct and excess mortality. The implications are deeply worrying.
The COVID-19 pandemic is a totalising event – affecting virtually every country, city and neighbourhood on the planet. It is also laying open the social and economic fault lines in our urban spaces. Predictably, many governments, businesses, and societies are looking inward, seeking to shore up their own health capacities and provide for their populations through aid and assistance. Yet the virus is revealing the extent of economic and social inequalities within many countries, including among OECD members. In the process, it is exposing the deficiencies of the social contract and the ways in which certain people – especially the elderly, poor, homeless, displaced – are systematically at-risk. While media attention is growing, there is comparatively limited investment in protecting refugees and displaced people facing infectious disease outbreaks. As public awareness of the sheer scale of infection, hospitalisation, and case fatalities becomes clearer in lower- and middle-income settings, we can expect this to change; at which point it may be too late.
TNH: Can you give us a sense of the scale of the problem in the world’s megacities and slums, where social distancing and self-isolation are a fantasy for many?
Muggah: According to the UN, there are about 33 megacities with 10 million or more people. There are another 48 cities with between five and 10 million. Compare this to the 1950s when there were just three megacities. Most of these massive cities are located in Africa, Asia, and Latin America. Many of them are characterised by a concentrated metropolitan core and a sprawling periphery of informal settlements, including shanty-towns, slums, and favelas. Roughly 1.2 billion people live in densely packed informal settlements characterised by poor quality housing, limited basic services, and poor sanitation. While suffering from stigmas, these settlements tend to be a critical supply of labour for cities, an unsatisfactory answer to the crisis in housing availability and affordability. A challenge now facing large cities is that, owing to years of neglect, informal settlements are essentially "off the grid", and as such, difficult to monitor and service.
There are many reasons why large densely populated slums are hotbeds for the COVID-19 pandemic and other infectious disease outbreaks. In many cases, there are multiple households crammed into tiny tenements making social distancing virtually impossible. In Dharavi, Mumbai's largest slum, there are 850,000 people per square mile. Most inhabitants of informal settlements lack access to medical and health services, making it difficult to track cases and isolate people who are infected. A majority of the people living in these areas depend on the services and informal economies, including jobs, that are most vulnerable to termination when cities are shut down and the economy begins to slow. Strictly enforced isolation won't just lead to diminished quality of life, it will result in starvation. A large proportion of residents also frequently suffer from chronic illnesses – including respiratory infections, cancer, diabetes, and obesity – increasing susceptibility to COVID-19. These comorbidities will contribute to soaring excess deaths.
All of these challenges are compounded by the systemic neglect and stigmatisation of these communities by the political and economic elite. Violence has already erupted in Ethiopia, Kenya, India, Liberia, and South Africa as police enforce quarantines. In Brazil, drug trafficking organisations and militia groups are enforcing social distancing and self isolation in lieu of the state authorities. In Australia, Europe, and the United States, racist and xenophobic incidents spiked against people of Asian descent. There is a real risk that governments ramp up hardline tactics and repression against marginalised populations, especially those living in lower-income communities, shanty-towns, and refugee and displaced person camps.
TNH: How seriously were international aid agencies and other humanitarian actors taking calls to scale up urban preparedness and response before this pandemic, and to what extent is COVID-19 a wake-up call?
Muggah: The global humanitarian aid sector was aware of the threat of a global pandemic. For more than a decade the WHO, several university and research centres, and organisations such as the CDC, the Wellcome Trust, and the Bill and Melinda Gates Foundation have publicly warned about the catastrophic risks of pandemic outbreaks. The international community experienced a series of jolting wake-up calls with SARS, H1N1, Ebola, and other major epidemics over the past 20 years, though these were typically confined to specific regions and were generally rapidly contained. Although fears of potential outbreaks emerging from China were widely acknowledged, the sheer speed and scale of COVID-19 seems to have caught most governments, and the aid community, by surprise.
With notable exceptions such as Singapore or Taiwan, there has not been major investment in preparing cities for dealing with pandemics, however. Most attention has been focused on national capacities, and less on the specific capabilities of urban governments, health and social safety-net services. Together with Georgetown University's Center for Health Sciences and Security, the Igarape Institute highlighted the importance of networks of mayors to share information and strategies in 2018. This call was highlighted by the Global Parliament of Mayors in 2018 and 2019. Starting in March 2020, the Bloomberg Foundation established a mayors network focusing on pandemic preparedness in the US. The Mayors Migration Council, World Economic Forum, and UN-Habitat are also looking to ramp up assistance to cities. What is also needed are systems to support mayors, city managers, and health providers in lower- and middle-income countries.
TNH: Part of the problem is that cities are unfamiliar territory for humanitarian responders, with many new actors to deal with, from local governments to gangs. What relationships and skill sets do they need to cultivate?
Muggah: Well before the COVID-19 pandemic, many humanitarian agencies were already refocusing some of their operations toward urban settings. International organisations such as the International Committee of the Red Cross, Médecins Sans Frontières, and Oxfam set up policies and procedures for engaging in cities. There is a growing recognition across the relief and development sectors of the influence and impacts of urbanisation on their operations and beneficiary populations. This is more radical than it sounds. For at least half a century, most aid work was predominantly rural-focused. This was not surprising since most people in developing countries lived in rural or semi-rural areas. This has changed dramatically, however, with more than half of the world's population now living in cities. Over the next 30 years, roughly 90 percent of all urbanisation will be occurring in lower- and middle-income countries – predominantly in Africa and Asia. The aid community only started to recognise these trends relatively recently.
Three priorities for urban pandemic response:
- Rapidly coordinate: don’t undermine local response.
- Act quickly: don’t let perfection be the enemy of the good.
- Duty of care: pay attention to staff safety needs – including local partners.
Working in urban settings requires changes in how many international and national aid agencies operate. For one, it often depends less on direct than indirect delivery, working in partnership with municipal service providers. It also requires less visible branding and marketing strategies, shoring up the legitimacy of public and non-governmental providers with less focus on the contribution of relief agencies. In some cases, aid agencies are also required to work with, or alongside, non-state providers, including armed groups. For example, in some Brazilian, Colombian, and Mexican cities organised crime and self-defence groups are engaged in social service provision, raising complex questions for aid providers about whether and how to support vulnerable communities. Similar challenges confronted aid agencies working to provide relief in Ebola-stricken villages in eastern DRC.
A diverse range of skill sets is required to navigate support to cities affected by epidemics, including COVID-19. Some cities may need accounting assistance and expertise in budgeting to help them rapidly procure essential services. Other cities may require epidemiological and engineering capabilities to help develop rapid detection and surveillance, as well as "surge" capacity including emergency hospitals, clinics, and treatment centres. A robust communications and public outreach strategy is essential, particularly since uncertainty can contribute to social unease and even disorder. Moreover, rapid resource injections to help cities provide safety nets to the most vulnerable populations are critical, particularly as existing resources will be redirected to shoring up critical infrastructure and recurrent expenses will be difficult to cover owing to reduced tax revenue.
TNH: Name three things aid agencies need to do quickly to get to grips with this?
Muggah: There are a vast array of priorities for aid agencies in the context of pandemics. At a minimum, they must rapidly coordinate with public, private, and non-governmental partners to ensure they are effectively contributing rather than creating redundancy or unintentionally undermining local responses. Humanitarian organisations must also act rapidly, especially in the face of an exponential crisis such as the COVID-19 pandemic. Agencies cannot let perfection be the enemy of the good, and focus on delivering with speed and efficiency, albeit while being mindful of the coordination challenges above. Aid agencies must also be attentive to the health, safety, and wellbeing of their own personnel and partners – they must avoid at all costs becoming a burden to hospital systems that are already overwhelmed by the crisis.
The first thing aid agencies can do is reach out to frontline cities and assess basic needs and their organizational potential to contribute. A range of priorities are likely, including the importance of ensuring there are adequate tests kits and testing capacities, sufficient trained health professionals, medical supplies (including ICU and ventilation capacities), and related equipment for frontline workers. Providing supplementary capacity as needed is essential. Consider that in South Sudan there are believed to be just two ventilators, and in Liberia there are reportedly only three. Other critical priorities are ensuring the integrity of the local food supply and attention to critical infrastructure. This may involve deploying a surveillance system for monitoring critical supplies, providing supplementary cash and food assistance without disrupting local prices, and ensuring a capability to rapidly address distribution disruption as they arise. Aid agencies can also help leverage resources to settings that are neglected, helping mobilise funds and/or in-kind support for over-taxed public services.
TNH: Cities like Singapore and Taipei, Hangzhou in China – to an extent Seoul – have had some success in containing COVID-19. What can other cities learn from their approaches?
Muggah: Cities that are open, transparent, collaborative, and adopt comprehensive responses tend to be better equipped to manage infectious disease outbreaks than those that are not. While still too early to declare a success, the early response of South Korea, Singapore, and Taiwan to the COVID-19 pandemic stands out. Both Taipei and Singapore applied the lessons from past pandemics and had the investigative capacities, testing and detection services, health systems and, importantly, the right kind of leadership in place to rapidly take decisive action. They were able to flatten the pandemic curve through early detection thus keeping their health systems from becoming rapidly overwhelmed.
Not surprisingly, cities that have robust governance and health infrastructure in place are in a better position to manage pandemics and lower case fatality rates (CFR) and excess mortality than those that do not. Adopting a combination of proactive surveillance, routine communication, rapid isolation, and personal and community protection (e.g. social distancing) measures is critical. Many of these very same measures were adopted by the Chinese city of Hangzhou within days of the discovery of the virus. Likewise, the number, quality, and accessibility (and surge capacity) of hospitals, internal care units, hospital beds, IV solution and respirators can determine whether a city effectively manages a pandemic, or not. The SecDev Group is exploring the development of an urban pandemic preparedness index to help assess health capacities as well as social and economic determinants of health. A digital tool that provides rapid insights on vulnerabilities will be key not just to planning for the current pandemic, but also the next one.
TNH: You’ve spoken in the past about the need to develop a pandemic preparedness index. INFORM has one and Georgetown Uni has a health security assessment tool. Are these useful? What is missing?
Muggah: The extent of a city’s preparedness depends on its capacity to prevent, detect, respond, and care for patients. This means having action plans, staff, and budgets in place for rapid response. It also requires having access to laboratories to test for infectious disease and real-time monitoring and reporting of infectious clusters as they occur. The ability to communicate and implement emergency response plans is also essential, as is the availability, quality and accessibility of hospitals, clinics, care facilities, and essential equipment.
To this end, the Center for Global Health Science and Security at Georgetown University has created an evaluation tool – the Rapid Urban Health Security Assessment (RUHSA) – as a resource for assessing local-level public health preparedness and response capacities. The RUHSA draws from multiple guidance and evaluation tools. It was designed precisely to help city decision-makers prioritise, strengthen, and deploy strategies that promote urban health security. These kinds of platforms need to be scaled, and quickly.
There is widespread recognition that a preparedness index would be useful. In November of 2019, the Global Parliament of Mayors issued a call for such a platform. It called for funding from national governments to develop crucial public health capacities and to develop networks to disseminate trusted information. The mayors also committed to achieving at least 80 percent vaccination coverage, reducing the spread of misinformation, improving health literacy, and sharing information on how to prevent and reduce the spread of infectious disease. A recent article published with Rebecca Katz provides some insights into what this might look like.
TNH: All cities are not equal in this. Without a global rundown, do you have particular concerns for certain places – because they are transmission hubs that might be hit worse, or due to existing insecurity and instability?
Cities are vulnerable both to the direct and indirect effects of COVID-19. For example, cities with a higher proportion of elderly and inter-generational mingling are especially at risk of higher infection, hospitalisation, and case fatality rates. This explains why the pandemic has been so destructive in certain Italian, Spanish, and certain US cities in Florida and New York where there is a higher proportion of elderly and frequent travel and interaction between older and younger populations. By contrast, early detection, prevention, and containment measures such as those undertaken in Japanese, South Korean, and Taiwanese cities helped flatten the curve. Yet even when health services have been overwhelmed in wealthier cities, they tend to have more capable governments and more extensive safety nets and supply chains to lessen the secondary effects on the economy and market.
Many cities in Africa, South and Southeast Asia, and Latin America are facing much greater direct and indirect threats from the COVID-19 pandemic than their counterparts in North America, Western Europe, or East Asia. Among the most at-risk are large and secondary cities in fragile and conflict-affected countries such as Afghanistan, Colombia, DRC, Iraq, Myanmar, Nigeria, Somalia, South Sudan, Syria, and Venezuela. There, health surveillance and treatment capacities are already overburdened and under-resourced. While the populations tend to be younger, many are facing households that are already under- or malnourished and the danger of comorbidity is significant. Consider the case of Uganda, which has one ICU bed for every one million people (compared to the United States, which has one ICU bed for every 2,800 people). Specific categories of people – especially those living in protracted refugee or internal displacement camps – are among the most vulnerable. There are also major risks in large densely populated cities and slums such as Lagos, Dhaka, Jakarta, Karachi, Kolkata, Manila, Nairobi, or Rio de Janeiro where the secondary effects, including price shocks and repressive police responses, as well as explosive protests from jails, could lead to social and political unrest.
TNH: The coronavirus itself is the immediate risk, but what greater risks do you see coming down the track for poorer people in urban settings?
Muggah: The most significant threat of the COVID-19 pandemic may not be from the mortality and morbidity from infections, but the political and economic fallout from the crisis. While not as infectious or lethal as other diseases, the virus is obviously devastating for population health. It is not just people dying from respiratory illnesses and organ failures linked to the virus, but also the excess deaths from people who are unable to access treatment and care for existing diseases. We can expect several times more excess deaths than the actual caseload of people killed by the coronavirus itself. The lost economic productivity from these premature deaths and the associated toll on health systems and care-givers will be immense.
“The most significant threat of the COVID-19 pandemic may not be from the mortality and morbidity from infections, but the political and economic fallout from the crisis.”
COVID-19 is affecting urban populations in different ways and at different speeds. The most hard-hit groups are the urban poor, undocumented migrants, and displaced people who lack basic protections such as regular income or healthcare. Many of these people are already living in public or informal housing in under-serviced neighbourhoods experiencing concentrated disadvantage. The middle class will also experience severe impacts as the service economy grinds to a halt, schools and other services are shuttered, and mobility is constrained. Wealthier residents can more easily self-isolate either in cities or outside of them, and usually have greater access to private health alternatives. But all populations will face vulnerabilities if critical infrastructure – including health, electricity, water, and sanitation services – start to fail. Cut-backs in service provision will generate first discomfort and then outright protest.
Most dangerous of all is the impact of COVID-19 on political and economic stability. The pandemic is generating both supply and demand shocks that are devastating for producers, retailers, and consumers. Wealthier governments will step in to enact quantitative easing and basic income where they can, but many will lack the resources to do so. As income declines and supply chains dry up, panic, unrest, and instability are real possibilities. The extent of these risks depend on how long the pandemic endures and when vaccinations or effective antivirals are developed and distributed. Governments are reluctant to tell their populations about the likely duration, not just because of uncertainties, but because the truth could provoke civil disturbance. These risks are compounded by the fact that many societies already exhibit a low level of trust and confidence in their governments.