Impact of COVID-19 on those on fringes of healthcare: Urban & Rural Perspectives I Part 3

21 May 2020

Impact of COVID-19 on those on fringes of healthcare: Urban & Rural Perspectives I Part 3

For many living on the fringes of society, public health care services are often inaccessible. The impact of the COVID-19 pandemic on the most vulnerable populations of our society -- migrant workers, the urban poor and daily wage earners, tribal communities, and agricultural men and women -- are deep and far-reaching. In the ‘Webinar on COVID19: Ask The Experts – Part 6’, we explored the impact of the COVID-19 pandemic on the health of vulnerable populations. Our guest experts – Yogesh Kalkonde, Divya Varma and Gautam Bhan – discussed unique health challenges posed by the pandemic for urban and rural populations; communication and community engagement strategies to mobilize/reach help to the vulnerable communities; lessons for urban-planning from COVID-19; and, impact on the health of migrant workers and their entrenched relationship with urban India.

This is the third part of the edited excerpts from the webinar, wherein Gautam Bhan, Senior Lead, Academics & Research, Indian Institute of Human Settlements, highlights the impact of COVID-19 and lockdown on informal settlements in urban areas.

I would like treat these two aspects differently - the notions of the informal worker and informal economy as a particular site for the lock down and lockdown-specific approaches to informal settlements. I think that this distinction is important in thinking about informality since the nature of informal work is different from the spatial nature of informal settlements. 

The geographer Neil Smith after the Hurricane Katrina floods in the US had actually said there is no such thing as a natural disaster. And I think that it is a very timely reminder to say that the exposure may be external, but disasters make visible pre-existing vulnerabilities that both shape the experience of a shock and also the way you're able to recover from that shock. So, we have to be able to use COVID-19 as a kind of diagnostic to understand what are the pre-existing vulnerabilities that are causing the disaster to take the shape it is - it is not just a question of something happening to us from the outside.

A case of missing social protection

The nature of relief is inversely proportional to the depth of your pre-existing social protection, which means, the more you had institutions and entitlements that allowed a safety net for all residents, the more you have an institutional structure that always delivered health, food, housing water and sanitation at a universal dignity/minimum threshold, you can use those same institutions to repurpose it thoroughly. Kerala is an excellent example because it had decentralized institutions of public feeding. It can do massive Community Kitchens because the labour and the institutions exist. In Delhi – which is doing an admirable effort at large-scale feeding – it has still has to create an additional 1,500 schools from which to give ration to non-ration cardholders because those systems don't exist. All of us need to be asking this in each of our states and in each of our cities: was there a need to come up with new delivery mechanisms for relief measures? Every time we come up with a new delivery mechanism for the relief measure, it tells us that institution did not exist before the crisis. It gives a map of the missing social protection.

The provocation I want to give and leave you with, is that much of what we are calling expanded relief in response to this crisis is actually the social protection we should have in normal times before the crisis hits. Repeated waves of global pandemic are going to be the reality for the generations to come. COVID-19 is not the first and it is not going to be the last, so we have to reduce pre-existing vulnerabilities. This crisis has made us see that even though levels of poverty have declined in India over the last 15 years, the levels of vulnerability may not have declined the same way. Which means that, for many households that go out of poverty, it takes only one shock to drop them back. Now, that shock can be an injury and illness, a wedding, a funeral, a bad monsoon, or a different kind of shock that drops people back to recognizing the vulnerable nature of poverty. That's why that metaphor is often used for social protection, to think of it as a safety net.

If we're thinking about informal settlements with the tenure illegality, the housing uncertainty of people who live in dense informal settlements, at this point is exacerbating their vulnerability to cope with the crisis. The absence of sanitation facilities at a universal level in informal settlements is exacerbating an exposure and coping to crisis. So, we're essentially putting our finger on pre-existing vulnerabilities. What's happening is that the social protection gaps that were earlier there, are also preventing an adequate disaster risk reduction and mitigation response.

Let me take a very particular example of the informal settlement to make this point. When you look at informal settlements, it’s important to recognize COVID-19 and lockdown as two different shocks. What's happening in COVID-19 plus lockdown in informal settlements is the livelihood uncertainty. It's very important to realize that they are different kinds of shocks at 5, 15 and 30 days. At 5 days, their savings begin to run out; at 15 days, food begins to run out and at 30 days, rent begins to kick in, so they see a series of interconnected shocks that we have to differentiate. Second, the urban environment they live in is dense, which is inadequately serviced with infrastructure.

COVID19 as a diagnostic for social protection

There is nothing that can compensate as relief if you have pre-existing gaps and structural absence of social protection. The current crisis should be a diagnostic that tells us of the kind of social protection system we should have. We must hold on to everything that is being today called relief, and turn it into normal social protection 6 or 12 months from now. We must not see this as a temporary creation of structures - all the innovations, all the new cash transfers, all the ration being given to non-ration cardholders. This is the description of the system we must have, this is not the description of adequate relief. This should be the description of the norm.


Case for a ‘community quarantine’

When we think a little bit about what informal settlements can be doing, the lessons from Ebola outbreak in managing responses is a key archive all of us should be turning to. It taught us that countries that were able to overcome that epidemic did so because communities were empowered for voluntary disclosure of symptoms. It was not as just a surveillance-based approach. It was an approach that trusted and worked with communities to say ‘let community-based associations and actors be the first forefront in this fight’.

What would empower someone to voluntary declare symptoms? Four core things. One, dignified quarantine, which is transparent, which is known from advance and is public; everyone knows where they will go should they declare symptoms. Two, economic compensation for the household, should a working member of the family or an adult member of the family need to go into quarantine. What is very important that it cannot be the economic compensation of an individual wage. It has to be an economic compensation for a household. Three, the food security and social protection for the household during the period of quarantine and before. Four, the option of thinking of a gap and middle solution between stay at home quarantine, only possible for the elite, and central quarantine or a public warranty which many communities distrust because of a long history of distrust of state capacity.

Many of the communities that I know have the capacity – if they are given resources and leadership – to generate what we can call a community quarantine, which is a quarantine that is created at settlement-level through the repurposing of built environment. It could take three or four shacks that are isolated, or one particular gully or a narrow lane in a settlement that is cordoned off, not through a surveillance police pressure of sealing alone but actually done through community action.  

Many communities I know in informal settlements in the cities are already doing this on their own. In dense informal settlements, the scale of quarantine cannot be the house. You cannot expect 8 to 10 people of a family to be stay-at-home quarantined in a house which is smaller than 40 square meters. So, the scale of quarantine has to be the narrow street that is in North Indian language is often called the gully. The minute you change the scale of quarantine to the gully, the infrastructure of safety and entry/exit changes. The mouth of the gully becomes sanitization point, a public sanitization point. The community quarantine can also work the same way. We have to be able to work with communities. What stops this from happening? Two things – one, without adequate food security and social protection many of these communities are saying something very simple. The lockdowns point its outcome is to prevent death- what they are saying is we also are trying to prevent death. The death that occurs due to economic hardship, a death if that occurs due to a non-COVID-19 health issue and a death that occurs due to COVID-19 are all three equally likely vectors to death for poor communities. We have to absolutely understand that the COVID-19 death should be prevented, but the consequence of economic death and non-COVID-19-related health deaths have to be prevented at the same time.

Empowering communities for ‘community-led quarantine’

We need to think about a specific approach to informal settlements that is community-led. It explores community quarantine where possible with encouraging voluntary disclosure of symptoms and an approach that partners with communities instead of surveying them. Create information and practices that are rooted in their life and worlds, and trust them to be able to be engaged and empowered to take care of themselves. Don’t treat them as populations that have to be protected but actual experts, who know how to manage community affairs more than any of us who don't live in this community.

Therefore, we must empower communities to make trade-offs and decisions at the community level. And why is this not happening? Because in the history of these communities and their current relief lockdown both, the first interaction is with the punitive arm of the state. It is with the police. It is not actually with health workers. It is not an invitation to work and lead a response when the community appreciates the risk that is happening to it. I understand that some communities are more organized than others, but communities have the ability to respond to this organization if the invitation is extended.

What is also required is very specific and targeted information for health practices that are appropriate to dense informal settlements. It should not be “wash your hands and you sanitize”. It should be - how do you make sure that you are risk-free if the water runs out. How do you have sanitary practices at a public toilet? How do you think about crowding in density and use the gully as a space of sanitation and not the house? I’m very happy to see that the office of the Principal Scientific Advisor to the Government has released informal settlements-specific communication guidelines a few days ago. I think that's the first step in this direction, but we need to understand and give information that respects people's context and allows for their leadership.


Universal social protection

The idea of the ‘universal’ that has come back into social protection discourse is a very welcome return. We’ve got to let go of targeting, focused social protection only to BPL (below poverty line), and stop worrying about the type two error and the false inclusion. We've got to start saying that anyone who's remotely at risk should be included. If some people who aren't at risk are included that's a price worth paying. Universal approaches mean that our data faults are overcome. They are easier to deliver and monitor.

Systems that are universal will always function better than system that are targeted, especially in a country like ours with societal fault lines and weak state capacity.


Watch the full webinar HERE