The remit of ARISE is to work on accountability and health in low- and middle-income countries. As the settings that we work in have become increasingly affected by the COVID-19 pandemic, we have had to adapt our research and interventions with people living in informal settlements to be part of the response.
Over the past few weeks, we have had increased calls for assistance from outside organisations. People like us, who are trying to prepare their health and community systems to prevent transmission of COVID-19 and put in place policies and interventions to care for those who are affected.
The specific challenges of this pandemic are rapidly evolving and vary significantly across different settings. But there are some commonalities. Successful interventions are likely to involve community engagement and to be very tailored to context. The pandemic will also affect some people more than others. Far from being a ‘great equaliser’, vulnerabilities to infection, severity of symptoms and socio-economic impacts follow well-worn social fault-lines and inequities which will vary according to where you are.
Many of our colleagues have lived and worked through many crises, including war, climate disasters, civil unrest, and previous pandemics. This crisis is both worryingly new and wearyingly familiar. More hopefully, the crisis has also made visible the resilience and strength of many ordinary people and how this is underpinned by long-standing social solidarity and action.
As a consortium, the approach we are taking is to: 1) Share, communicate and support each other across contexts and areas of expertise; 2) Draw on pre-existing relationships and organisational strengths to add value; 3) Focus on the most vulnerable; 4) Advocate for change.
We are sharing this update in case it can help you strategise about what to do in your own communities.
Sharing, communicating and supporting each other
Firstly, we focus on promoting awareness about COVID-19 and communicating accurate information about the virus and its medical impacts. We sought expert advice from Tom Wingfield at the Liverpool School of Tropical Medicine. He answered questions and concerns that were raised by federations of the urban poor via Slum Dwellers International in a short film.
Our focus was on evidence-based ways to reduce transmission, including handwashing and physical distancing, and we also promoted keeping mentally healthy. In many of the settings where we work, this is challenging and undermined by myths and misinformation. Ensuring that accurate and understandable information is available has been a first step to countering this. But we are also remaining alert to what myths are circulating as these can often provide insights into how illnesses and subsequent interventions are viewed.
In India, the team at The George Institute for Global Health India (TGI) has crowdsourced context-specific Information Education and Communication resources to share with its partners in Shimla, Bengaluru, Vijayawada and Guntur. Since a lot of the government advice is not the most appropriate for waste picking communities and are often difficult to comprehend, partner organisations have developed stories and cartoons, to communicate better. Additionally, TGI is supplementing the efforts of its partner organisations, in raising funds for the vulnerable and marginalised communities, especially waste pickers and sanitation workers.
Our colleague Annie Wilkinson (Institute of Development Studies) drew together a rapid briefing that sets out key considerations for protecting informal urban settlements from the spread and impacts of COVID-19. It discusses what is known about vulnerabilities and how to support local action.
At the consortium level we are offering call-down mental health support to anyone working for partner organisations providing services or support to people with COVID-19 and communities.
Drawing on pre-existing relationships and organisational strengths to add value
Partners have adapted information on COVID-19 for use in different ways. Some of our partners are health service providers who are able to use pre-existing information channels to respond to COVID-19. For example, in Kenya, LVCT Health use multiple technologies to widen their reach, such as an information hotline and SMS messages to existing clients. Through this they have already reached 25,000 Community Health Volunteers, 34,000 adolescents and 53,000 girls.
Prior to restrictions on movement in Sierra Leone, Bangladesh, India and Kenya, Community Health Workers and Volunteers visited marginalised people in their homes to deliver messages on prevention in simple language. In Bangladesh, 50,000 of BRAC’s Community Health Workers provided information to 1.2 million homes.
Other partners supported preventive approaches in their interactions with communities and have mobilised funds for handwashing resources such as buckets and soap. APHRC, through the NUHDSS field team has been raising community awareness on COVID-19 in Korogocho, Viwandani and Mathare slums. Working with Sub-County Health Management teams, masks, sanitizers and tanks for hand washing have been provided for Community Health Volunteers.
Focusing on the most vulnerable
ARISE partners have developed different approaches to reach people who are often excluded from communication strategies. For example, LVCT Health created a public information film on COVID-19 for the deaf community in Kenya. We also hosted a Twitter Chat to explore how people with disabilities are included in the response, highlight needs of people with disabilities, identify people, organisations and networks with expertise in disability and source further resources. LVCT Health drew on existing trusting relationships with sex worker communities to discuss their concerns with preventive messages, which included anxieties around exacerbated police harassment and exploitation by clients.
Our focus on equity has also prompted reflection on careful use of language to avoid exacerbating entrenched social inequalities. For example, in India, TGI cautioned us about how ‘social distancing’ discourses have particularly problematic connotations in the context of centuries of caste discrimination. They recommended using ‘physical distancing’ phrasing.
Individuals, organisations and networks have been supporting community-based organisations to provide basic necessities, including food, to those with vulnerable livelihoods affected by restrictions on social movement, brought forth by the impositions of lockdowns. In Mumbai, long-standing savings groups (many of them led by women, such as Mahila Milan) have mobilised to make savings available to their members and have opened community kitchens. SPARC in Mumbai, Hasiru Dala in Bangalore and the Dalit Bahujan Resource Centre in Guntur and Vijayawada are at the forefront of distributing relief kits and meals to the most vulnerable, including waste pickers – who are unable to earn their daily living without freedom of movement and who are often excluded from government social protection schemes. In spite of the severe restrictions in place, volunteers from these organisations are spearheading the relief efforts and trying their best to ensure that no one remains hungry.
We anticipate that the crisis will exacerbate pre-existing psycho-social vulnerabilities of marginalised people. There are also likely to be mental health impacts on those providing support, including health workers and community organisers. Drawing on their experiences in the Ebola epidemic response, COMAHS in Sierra Leone are sharing resources and advocating for mental health support for health workers at all levels. Colleagues from TGI along with colleagues from other organisations, including SOCHARA, are developing an online tele-counselling system that matches volunteer counsellors with people seeking counselling in India. LVCT Health are running a call centre to offer counselling in Kenya.
Advocating for change
We are advocating for consideration of marginalised people in informal spaces in governmental and non-governmental responses to the COVID-19 pandemic.
SDI have developed key messages for city mayors and administrators which include that they become champions of the cities’ vulnerable and plan with care providers for one month after lock down. They have advocated that communities create registers of documentation of households with bank accounts and/or ration cards and locate households or individuals who may not have these and that they develop a report card of state (in)action.
In Kenya, APHRC, SDI and LVCT Health have joined forces to build on relationships with national and county government departments. They are advocating for attention to socio-economic vulnerabilities during lock-down in Kenya. SDI Kenya and Muungano Wa wanavijiji have developed a tool to remotely monitor cases in informal settlements to provide information to inform government responses.
FEDURP and COSOHSAPA have co-produced a Mitigation and Response Strategy for informal settlements in Sierra Leone.
BRAC JPG School of Public Health is providing technical support to both BRAC and the Government of Bangladesh to inform their response and have reorganised their website to become a source of evidence-based COVID-19 information.
In India, the Safai Mazdoor Union (a union of sanitation workers) in Shimla have successfully negotiated their demands with the Municipal Corporation to issue personal protective equipment (PPE) and sanitisers to all the sanitation workers and door-to-door garbage collectors in the city.
As part of the Jan Swasthya Abhiyan (People’s Health Movement), members from TGI are advocating for system level interventions to minimise the community impact of COVID-19, especially isolation and quarantine of patients suspected of, or diagnosed with COVID-19 infection, and working with the private health sector to share the public health system responsibilities and duties of care in the current crisis.
The ARISE team at TGI has also endorsed the demands put forth by the Alliance of Indian Waste Pickers (AIW) to the government – demanding PPE, providing public facilities to wash hands and waiving user fees for public toilets, providing ration including sanitisers, conducting regular health camps, given the close proximity among residents in the informal settlements; and compensating waste pickers’ families in case of fatality.
Looking forward and sharing learning
As the pandemic unfolds, we need to proactively anticipate and plan for the challenges we will face. We will be stronger if we can do this together as a global community and share learning from similar contexts. It is in this spirit that we are sharing our response so far.
As community-transmission increases and fragile health systems face pressure, we may need to consider evidence-based practices for community and home-based care for people with COVID-19. There may be much that we can learn from experiences of delivering such care across acute and chronic epidemics in low- and middle-income countries for example Ebola, HIV, Malaria and Tuberculosis.
Simultaneously we will also have to learn how to avoid health systems’ distortion by maintaining other essential preventive and curative health services, including routine vaccination, maternal, sexual and reproductive health services.
We must not forget issues of accountability during this pandemic. Our interactions and inputs now may create a path to a strengthened system of power sharing with equity and rights at its centre.
We believe that communities have the strength and ingenuity to make positive change. SDI have taught us all that, ‘Information is POWER.’ Unless the most vulnerable among us are safe and healthy, none of us are. So, please help us to strengthen the COVID-19 response in our countries and beyond by sharing your interventions and innovations.