What’s health got to do with World Habitat Day?

Epidemics are a window into society. They reveal our social relationships and circumstances. The global pandemic has brought to the fore the inequalities that persist within our towns and cities. The spread and the impacts of the disease have not been even. As the world continues to grapple with the fallout from the pandemic, this year’s World Habitat Day is an important, if not urgent moment to reflect on the interaction between pandemics, health and cities.

At the beginning of the pandemic, in my neighbourhood in London, there was a sense that we were all in it together. Yet, underlying this good spirit, the inequalities across cities and within cities have been undeniable. Across cities, there are differing health system capacities, economies, and infrastructure. While London had less acute care bed space than Berlin or Rome, it had more than many cities in the Global South; and the UK government was able to provide more economic support to the residents of London than was possible in Kampala or Dhaka.

There have been important inequalities between residents within cities. Facing lockdown in London was very different depending on whether you had a garden, could work from home and have your food delivered, compared to if you lived in a tower block, with limited space and perhaps had insecure work delivering food. Likewise, in cities like Mumbai, some people were able to protect themselves in private gated homes while others living in informal settlements could not socially distance or wash hands and found their livelihoods suddenly curtailed. Studies have found that 57 per cent of people living in ‘slum’ neighbourhoods in Mumbai had antibodies to COVID-19 compared to 16 per cent in ‘non-slum’ areas.

Cities on the frontline – but overlooked and misunderstood

With COVID19, most of the spread has been in urban settings – reflecting issues around space, connections, and density. Yet, COVID is not the only major epidemic the world has faced in recent years, and it continues a long list of outbreaks which have had urban dimensions for example Ebola in West Africa, Zika, Yellow Fever in Angola, or Cholera in Zimbabwe.

The major challenge is that our understanding of urban health has not kept up with patterns of urban development. The world is urbanising dramatically. The global population is now majority urban and the proportion of urban residents is increasing. Urban populations are growing fastest in the Global South. We know that inequality and poverty have a range of negative impacts on health but we do not clearly understand the social determinants of health in many of these rapidly growing urban settings. Urban-health interactions are overlooked and misunderstood; we know least about the most vulnerable settings and people, in particular, the one billion people living in informal settlements.

However, despite these very evident trends, spending on and attention to urban development is limited. Often there is a lack of urban policy, both at the national level and within key sectors e.g. in health or pandemic preparedness policies. While health receives significant aid funding, the urban development receives comparatively little. Another problem is that health experts are often disconnected from urban experts and planners. We are left with siloed health and urban activities. In addition, local expertise is too often ignored.

Most importantly, there is a politics of neglect when it comes to informal urban settlements. There is a severe lack of data and evidence on informal settlements in part because governments do not collect it out of the fear that it would validate the existence of settlements they deem to be illegal. Exclusionary policy and practice are evident in the way poorer and marginal residents are not routinely included in planning processes. All of this follows a long history of blaming the poor for their problems and treating them as vectors of disease, not as victims.

Clearly, there is an urgent need to better consider the characteristics of this urban growth and implications for health. Highest up on the ‘urban/health’ priorities should be informal settlements.

Improving our understandings of health in informal settlements

The first thing to note is that we cannot generalise about urban settings in the global south. Cities, settlements, and people are all very different, whether you are in Salvador in Brazil, Wuhan in China, or if you are a male migrant worker in India or a female low caste waste picker.

Informal settlements also look very different from one another. A case in point is in Freetown, Sierra Leone, where there is a dense settlement in downtown area on the coast built out of rubbish, and another is a hillside settlement on the outskirts of the city and much more spacious. They both have infrastructural challenges, but they are different.

A starting point is that heterogeneous social, political and economic relations shape urban spaces. Drivers of health and well-being comprise intersections between environmental deprivations and hazards as well as social marginalisation, stigma, violence. Ambiguous governance also shapes health. Cities have complex governance arrangements across sectoral, administrative and spatial scales, much of which is invisible and informal; as a result, accountability is unclear. It is a challenge to identify drivers of multiple, intersecting inequities in health and wellbeing and routes for redress.

So how do we address these challenges? Certainly, we need increased investment and attention to urban settings, and improved data. But perspective is also vital.

We need to do four things:

  1. Learn to ‘see like a city’ – we need to understand systems and interactions, and especially informal dynamics
  2. Learn to ‘see like a citizen’ – understand how people are expressing and understanding rights and entitlements, how they are claiming accountability and from who
  3. Consider invisibility – who and what is not seen, or not easily counted? For example displaced or migrant populations who cannot claim rights
  4. Focus on social infrastructures as much as the technical and medical, recognising that learning, dialogue, and collaboration are the key to progressive change.

It may feel hard to look to the future when we are still navigating our way through this global crisis. But what happens next depends on how we can diagnose and influence the power relations which have shaped urban development trends towards inequality and exclusion.

A key long-term response must be to marshal interdisciplinary, intersectoral and intersectional approaches, which pay attention to power dynamics, and most importantly, are inclusive of the most marginalised.

This blog by Annie Wilkinson and based on the author’s presentation for UN-Habitat Norway ‘World Habitat Day’ Webinar on Pandemics and Future Cities. It was first published on the IDS website and is repeated here with permission.

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