COVID-19 response and protracted exclusion of informal residents: why should it matter to city authorities in Freetown, Sierra Leone?

By Abu Conteh, Mary Sirah Kamara and Samuel Saidu Freetown is home to over one million people, with over 68 informal settlements spread across precarious land spaces. These settlements are often built on marginal lands around sea fronts, dumpsites and on dangerous mountain peaks, which always constitute high risks, but are made worse during health emergencies. Informal residents experience greater spatial inequalities than their formal counterparts. Inadequate provision of services including health, water and sanitation services highlight some of these spatial inequalities, which expose residents to different health circumstances. Narratives about exclusion have pervaded city planning for a long time, causing a vertical relationship between informal dwellers and policy makers. There is a top-down relationship between city authorities and informal dwellers, which excludes informal residents from decision making. Often, there is confusion around response to emergencies in these marginalised spaces due to dearth of data on varying levels of marginality. With COVID-19 spreading across communities, informal residents are not only at risk of contracting COVID-19 and other infectious diseases due to environmental conditions (including overcrowding) but are also experiencing loss of livelihoods as well as challenges in access to health, water and sanitation services. These conditions require quick response from city authorities to enhance an inclusive city planning and service delivery. How has the city responded to COVID-19? Response measures to reduce the spread of COVID-19 in Freetown have been fairly impressive. These measures include active case search and isolation, physical distancing and use of face masks. Social distancing has been enhanced mainly through nationwide lockdowns, curfews and inter-district travel restrictions. However, these response measures have been put in place with limited consultation with the vulnerable groups mostly living in informal spaces. There have been gaps in providing a guided response that meets the needs and wellbeing of informal settlement dwellers. During the lockdowns in April and May 2020, we conducted phone interviews with co-researchers and other informal residents living in Dwarzark, Moyiba and Cockle Bay. The interviews focused on the state of the COVID-19 response and impact on health and wellbeing of residents across our research communities. We would like to highlight the exclusion of informal residents in current response planning. We observed during our discussions with residents that they were deeply concerned about not being able to meet their most basic needs due to restrictions on movement. Healthcare access There has been a drastic reduction in the number of visits to the health centres during the COVID 19 restrictions, especially amongst non-beneficiaries of free health care (FHC) provision. For many non-beneficiaries of FHC, access to healthcare was limited due to restrictions on vehicle movement and okadas (motor bikes providing easy access to non-motorable and high traffic areas) during the lockdowns. Fear of being sick or showing any visible symptoms related to COVID-19 has also affected access to healthcare for many community members. Due to fear of being infected with COVID-19 and associated costs of seeking healthcare, people outside the FHC (adult males and females without disability and not non-Ebola survivors), self-medicated with medicines obtained from pharmacies and patent drug stores. Generally, people were afraid that their neighbours might call the emergency response number if they were found to be sick. Stigma around quarantine was one of the issues driving fear.  There were general misconceptions about COVID-19 and its spread, which can only be addressed through sustained engagement with communities. While residents were engaged in sensitizing their peers about seeking formal healthcare and maintaining confidence in the health system, their efforts were not synergised with health workers and responders. Sensitisation was done in parallel by informal residents and responders with minimal collaboration, and a lack of support for resident processes. Community Health Workers bridged this gap and volunteered to provide much needed sensitization to residents to follow health regulations and to avoid being infected. Messages disseminated included hand washing, maintaining social distancing and visiting the health facility when they thought they were sick. Residents requested for training by health workers to prevent spread of COVID-19. Food and livelihood challenges   Many informal residents in Freetown do not have sustained means of livelihood, and their income sources are linked to the informal economy. They survive mostly on hand to mouth and cannot afford food beyond a day. This makes stocking up on food very challenging. The relatively spontaneous lockdowns complicated the existing food access vulnerability of informal residents. Food prices increased rapidly in the periods before the lockdowns, and informal dwellers who rely on daily income suffered hunger. For example, the lockdown in May coincided with the Muslim fasting which contributed to the increase in food prices. In many of those circumstances, low income earners depended on their neighbours or relatives for help. A community resident remarked as follows in one of our interviews:
The food situation is bad for residents; I saw a young girl with a plastic bag looking for cooked food to buy for her family. I realized from that point that the girl’s family did not have raw food or rice at home to prepare for that day. I was worried that they might not have something to eat on the first day of the lockdown. At that time, we saw soldiers coming, so we ran away without being able to help to the young girl…As a widow and a single mother myself, it was not easy putting together some food for my children that will last us for three days. People are not happy, and the prices of food items are going up rapidly, so how can you manage to stock up food for a three-day lockdown. And moreover, this is a month of fasting when prices are generally high. (A widow at Moyiba)  
Owing to the vulnerability of many informal residents, many experienced severe hunger. In Dwarzark for example, many residents including homeless children and people with disability were concerned that their needs are not often considered in planning, so it becomes even more difficult for them during crisis periods. Many of these groups depended on NGO and community support during crisis, but these streams of support were not forthcoming during the lockdown restrictions. During the second lockdown, homeless children had no shelter to live and many were begging in the neighbourhoods for food. Community elders however recognised these challenges and arranged for shelter at the community centre.  Community elders also pleaded with residents who had enough food to provide for the homeless children. Water and sanitation   Persistent lack of access to water and sanitation services are among the most frequent concerns of informal residents. Most settlements are not connected to the national water grid, so they access water from different sources, some of which are of poor quality. Water tanks supplied by government to communities through the Sierra Leone Water Company (SALWACO) were considered useless by community residents because they have not been refilled since the Ebola period, some five years ago. These access concerns became more challenging during the lockdowns. In their desperate search for water, many people ignored social distancing regulations. Many of them clustered around the few water access points.
Residents of Dwarzark queuing up for water during lockdown
Residents of Dwarzark queuing up for water during lockdown
In Dwarzark (one of the hillside informal communities), most of the wells dried up completely at the peak of the dry season in April, so most residents relied mainly on a solar powered tank to regenerate water. In Moyiba (another hillside community), youths in charge of public taps or ‘‘tap collectors’’ developed a strategy of closing the taps from time to time to control the huge crowds and to enhance even distribution. They devised a way of preventing multiple access by identifying people who had already collected. Those who could not withstand the huge crowds travelled to nearby communities to access water. Children and women were mostly at the centre of water collection since schools had been closed by government to prevent spread of the virus. Children were therefore coming into contact with huge crowds during these interactions. Access to sanitation was also a challenge, since private indoor facilities are less common. Use of shared toilets or open defecation are widespread, which required people to risk leaving their homes or go to the streams or shared spaces. Moreover, outdoor toilets often exposed women and girls to sexual exploitation in informal settlements. Security concerns In addition to health, water and sanitation challenges, communities were also concerned about their security during lockdowns. Police and soldiers were deployed in communities to enhance adherence to response measures. Checkpoints were mounted with frequent patrols. There were incidents of beatings or arrests of people who ventured out to look for food and other basic needs by security personnel. For many residents, the food situation was so dire that they had to plead with their neighbours for food or money to buy basic food items. Women and girls are likely to be particularly vulnerable to public and private violence. This is an area that needs further exploration as recent crime statistics from the Sierra Leone Police reveal high rates of sexual violence and penetration of women and girls in Freetown. Such incidents could be higher in informal settlements where safeguarding awareness is low, coupled with increased risk of gender based violence. Lessons for future health responses Communities, especially informal settlements experience immense pressure to meet their daily needs, including food, water and sanitation services. Yet, they are not well considered in urban policy planning and emergency response by city authorities. In times of crisis, informal residents have shown much intuition to respond appropriately. With little resources, they provide relief support for their counterparts mostly in need of help. They organise fair distribution of scarce resources like water in accordance with social distancing regulations. The current COVID-19 response has shown that limited involvement of informal residents in planning and the response has caused severe hardships. An inclusive process of city planning is imperative for a socially just response that meets the needs of all. Yet, communities feel disempowered because they have not been provided with much support to enhance their local actions in the fight against COVID-19. This account of community agency shows the strong capacity of communities in organizing themselves during emergencies or crisis to promote safe health behaviours and reduce spread of infections. Such actions could be leveraged upon by health professionals and policy makers to improve community surveillance and health promotion. Special thanks to the following co-researchers who provided information and photos for this blog: Abu M. Sesay, Mohamed Bangura, Zakiatu Sesay Suad Kamara.