Open commentary

COVID-19 & informal settlements: is ‘Stay Home’ safe?

Authors
  • Emily Nix orcid logo (UCL Institute for Environmental Design and Engineering, Bartlett School for Energy, Environment and Resources, University College London, London, UK)
  • Jacob Paulose (UCL Institute for Environmental Design and Engineering, Bartlett School for Energy, Environment and Resources, University College London, London, UK)
  • Monica Lakhanpaul (Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, UK)
  • Pam Factor-Litvak (Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA)
  • Priti Parikh (Engineering for International Development Centre, London, UK)
  • Hector Altamirano-Medina (UCL Institute for Environmental Design and Engineering, Bartlett School for Energy, Environment and Resources, University College London, London, UK)
  • Yasmin Bou Karim (Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, UK)
  • Logan Manikam (Aceso Global Health Consultants Ltd, 3 Abbey Terrace, London SE2 9EY, UK)

Abstract

The disproportional burden of coronavirus (COVID-19) and vulnerability to containment measures in informal settlements have been recognised; however, the role of poor housing conditions in propagating these remains neglected. Poor housing conditions makes it difficult to effectively implement social distancing measures. With increased time spent in cramped, dark and uncomfortable indoor environments, water and sanitation outside the home, and no outdoor space, higher exposure to existing health hazards and high levels of stress, with women and children being most vulnerable, are anticipated. Through this commentary paper, we reflect on these interconnections and recommend immediate measures and the long-term need for adequate housing for health and well-being.

Keywords: informal settlements, housing, health, COVID-19

How to Cite: Nix, E., Paulose, J., Lakhanpaul, M., Factor-Litvak, P., Parikh, P., Altamirano-Medina, H., Bou Karim, Y., & Manikam, L. (2022). COVID-19 & informal settlements: is ‘Stay Home’ safe? UCL Open Environment, 4. https://doi.org/10.14324/111.444/ucloe.000038

Rights: © 2022 The Authors.

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Published on
28 Jul 2022
Peer Reviewed

Introduction

Preliminary evidence suggests that those in disadvantaged neighbourhoods, even in high-income countries such as the United States, will experience the largest coronavirus (COVID-19) health burden [1]. Informal settlements are home to some of the most disadvantaged populations globally, where residents face overcrowding, unstable incomes and poor quality housing on vulnerable lands at high risk of climate change impact [2]. One in eight people, or 881 million, live in slums globally; this number is expected to increase to 2 billion with population growth and urban migration over the coming decades, with Asia and Africa expected to see the biggest growth [3]. Conditions in informal settlements are not only likely to contribute to increased COVID-19 transmission risks, due to high contact rates and limited opportunities to practice good hygiene, but infections are likely to be more profound due to co-morbidities, food insecurity and lack of adequate healthcare services [3]. Research estimates that in refugee camps, where housing is similarly limited, large-scale outbreaks of COVID-19 are very likely [4]; however, modelling interventions in these settings suggests that use of face masks and efficient isolation could reduce the incidence of inflections [5]. Although stay-at-home orders are aimed at reducing COVID-19 transmission, such measures are likely to propagate income instability and increase exposure to existing housing-related health hazards in informal settlements.

Several published commentaries have discussed how to respond to COVID-19 in informal settlements or similar settings that suffer from poor housing and cramped conditions, such as in refugee camps [6]. For example, Corburn and colleagues [7] provide recommendations for food and income assistance, healthcare services, water, sanitation and waste collection and advise drawing on existing social groups. However, the impact of housing-related deficiencies, specifically, has garnered little attention. Drawing on our field experiences across India’s informal settlements, this commentary examines how housing conditions especially in informal settlements propagate inequalities in 1) the exposure to and 2) the burden of COVID-19 and 3) the unintended impacts of containment measures (Fig. 1). We consider these issues and the longer-term need to consider adequate housing on the global health and development agenda in order to reduce health inequalities and impacts in future pandemics.

Figure 1
Figure 1

Connections between (non-exhaustive) unsafe and crowded homes environments and COVID-19 vulnerability and burden in informal settlements.

Housing conditions in informal settlements and impacts on health and well-being

Housing in informal settlements tends to be extremely limiting [8]. Plot sizes are very small, typically no more than 15 m2, often placed in cramped back-to-back rows with walls and entrances shared with neighbours (Fig. 1). Housing is constructed incrementally, with most housing starting as single-room structures until households can invest in additional floors. Dwellings range from makeshift structures built from bamboo and plastic sheets to substantial structures of bricks walls and concrete roofs, with toilets incorporated where possible. These conditions result in inadequate ventilation and poor lighting levels and insufficient space for occupants, causing dwellings to become polluted and overheat, forcing residents to leave doors open or sit outside – exposing them to mosquitoes and other outdoor risks. Informal settlements generally do not have green space for exercise and well-being, have high levels of environmental pollution or are located on contaminated sites, such as landfills or nearby polluted water sources. Water and sanitation infrastructure are often at a community rather than household level, as is waste collection. Poor urban environment further contributes to the health burden through increased exposure to infections, pollutants and limited ability for healthy lifestyles.

These limiting conditions in informal settlements result in high risks of infection and injury, with children particularly vulnerable, due to malnutrition and recurrent diarrhoea resulting in stunted growth and long-term effects on cognitive development [3]. Previous research in an informal settlement in Delhi revealed how housing: was unable to provide safe indoor temperatures; had poor ventilation; experienced dampness and mould; used hazardous materials and were poorly constructed; experienced overcrowding; had poor lighting and little protection against noise; and suffered from a substantial presence of mosquitoes, pest and food infestation; and facilities for cooking, washing and sanitation were inadequate [8]. Furthermore, this research found that housing had a significant impact on the daily practices of women, as they dealt with the hazards and limiting conditions [8]. The limiting housing and environment conditions will result in health inequalities and increased levels of chronic disease and thus lead to a higher risk of severe outcomes from COVID-19.

Influence of housing conditions to COVID-19 vulnerability and unintended impacts of containment measures

Housing conditions will significantly limit the ability to implement measures intended to reduce the transmission of COVID-19. With limited indoor space or when people live in only a single room, there is little scope for social isolation within a household. This is an additional burden where multigenerational families stay in the same house, as is typical in India, posing a significant exposure risk to older people who are most vulnerable. There is often less than 2 m between neighbouring entrances, and streets are often less than 2 m wide, making it extremely difficult to maintain distance when leaving the house to collect necessary supplies and to gain access to outdoor air (Fig. 1). Poor air circulation and limited ventilation due to narrow streets are likely to increase the risk of infectious disease, as is found with tuberculosis [9]. Similarly, shared walls with high permeability between dwellings are unlikely to offer protection between households. This situation is further compounded by the frequent need to leave the house to access water sources and use communal toilet spaces; these challenges are discussed in detail in a sister commentary paper [10]. Moreover, with little to no income savings, residents’ ability to stock up on food and other supplies becomes very limited, thereby forcing residents to regularly access public distribution systems or the informal labour market. As a direct result of the home environment, it is very difficult to implement measures to reduce exposure to COVID-19, and thus controlling the spread will be extremely challenging in these settlements.

There are likely to be detrimental effects on health with increased time spent inside in dark, cramped and uncomfortable environments with no or limited private outdoor space. For instance, the current lockdown coincides with India’s peak summer temperatures over 45°C, and with poor housing, temperatures indoors are likely to be higher than the outdoor temperature [8], and if residents are unable to access shade outdoors or cooling appliances the consequences on mortality could be catastrophic. With more occupants remaining indoors, indoor conditions are likely to become hot and stuffy and the ability to move around and complete daily tasks more stressful and result in increased accidents. Furthermore, the risk of contracting other infectious diseases or mosquito-borne diseases (e.g., dengue) could be higher due to increased contact with more people remaining at home. As regards cooking, our previous observations are that children are typically found outside; however, if children remain inside they are likely to have increased exposure to indoor pollution and increased risk of burns and accidents. The small houses provide limited opportunity for productive study or work and the cramped conditions are likely to result in the feeling of suffocation and poor mental health. Women and children are most likely to be affected by these stresses, as a result of an increase in domestic violence – which has been reported globally [11]. The situation is likely to be extremely grave in households with very limited space, as women and children have no respite from their abusers.

Reflections and recommendations

With widespread social distancing and stay-at-home orders, access to adequate housing and making human settlements safe for health and well-being has never been more important. The COVID-19 pandemic is highlighting the gross inequalities and deficiencies in housing infrastructure. Poor housing conditions surrounding urban form have significant influence not only on vulnerability to COVID-19 but also on potential exposure to COVID-19 and adverse impacts of the lockdown measures.

Improved housing must be part of measures to reduce the burden of infectious diseases and to support the containment of future disease outbreaks. Governments and organisations must start to recognise the role of housing in health inequality and support improved housing for all. Housing quality has too often been missed from the global health agenda, and viewed only through the lens of affordability and access. Current definitions for adequate housing rely on simple characteristics (e.g. whether a house is built from finished materials) which can be not linked to requirements for health [12]. While the recent World Health Organization (WHO) Housing and Health Guidelines [13] are a useful starting place, these must be expanded to include other risks (such as lighting levels, mosquito-borne diseases and pests) and be translated for use in the limiting conditions of informal settlements and be adapted to geographical and social contexts.

In the immediate term, focus needs to be given to those living in the most unsafe dwellings, with remediation measures carried out or alternatives provided. Clean cooking fuel and stoves, mosquito nets and protective equipment should be provided for mitigating both existing risks and increased risks during the COVID-19 pandemic. Cooling appliances, electricity subsidies or access to cool places, such as community centres, should be provided during periods of extreme temperatures and households should not be penalised for leaving their homes. Support should be given to those most vulnerable to COVID-19 and the impacts of lockdown measures, for example, the elderly or women and children at risk of domestic abuse. As outlined elsewhere, action plans should be developed with the local community and agencies with experience in providing support [7]. This approach of local community action, use of mobile clinics and widespread community testing was reported to have successfully curbed COVID-19 within Mumbai’s largest slum [14]. Yet, infection rates were found to be three times higher in Mumbai’s slums compared to other areas [15] and later India faced a huge surge in COVID-19 outbreaks and related deaths [16] – highlighting the long-term need to tackle the poor housing conditions.

Small-scale interventions, such as shading or screens for mosquitoes, can be easily implemented to alleviate some housing deficiencies. Housing design manuals and guidelines should be developed for high-density settings to inform improvements for ventilation, lighting, layouts and other aspects. There needs to be a move away from community-level services in informal settlements and it should be ensured that every household has access to basic amenities at home; COVID-19 highlights the deficiencies in a settlement-level approach. Capacity building programmes are vital to build awareness of health and housing and safe construction practices, appropriate materials and low-cost interventions. Such programmes could form expert community groups that can bridge between the community and government at such times of distress, acting as the frontline workers to better implement and develop effective containment measures.

The authors are members of the Childhood Infections and Pollution (CHIP) Consortium aimed at reducing the infection and antimicrobial resistance amongst children under five in slums using a One Health (i.e., human, animal, environment) and technology-enabled citizen science approaches. The Consortium has undertaken work in urban slums in Jaipur, Jakarta and Antofagasta.

In addition to the authors, members of the CHIP Consortium consists of Prof Wiku Adisasmito, Shereen Al Laham, Dr Alexandra Albert, Anila Atin, Dr Neha Batura, Yebeen Ysabelle Boo, Hemant Chaturvedi, Meghan Cupp, Prof Rajib Dasgupta, Prof Keiji Fukuda, Julia Vila Guilera, Prof Muki Haklay, Dr Rebecca Katz, Dr Rajesh Khanna, Dr Sanweer Khatoon, Dr Nancy Leung, Dr Clare Llewelyn, Ria Marwaha, Chyntia Mayadewi, Natasha Mayandra, Dr Krishna Mohan, Dr Rintaro Mori, Dewi Nur Aisyah, Dr Prejit, Prof Erika Ota, Dr Raj Panda, Prof Joseph Malik Peiris, Dr Mahen Perera, Satya Prakesh, Rajendra Prasad, Dr Obaidur Rahman, Dr Omar Risk, Dr Kaushik Sarkar, Sanjay Sharma, Radhika Sharma, Premraj Sharma, Mr Sandeep Soni, Dr Pradeep Srivastava & Dr Hein Min Tun.

Consortium members had an opportunity to critically review results and contribute to the process of finalisation of this paper. The co-authors vouch for the accuracy and integrity of the work, and accept full responsibility for the content of the paper.

Declarations and conflicts of interest

Research ethics statement

The authors declare that ethics approval was not needed for this article.

Consent for publication statement

The author declares that research participants’ informed consent to publication of findings – including photos, videos and any personal or identifiable information – was secured prior to publication.

Conflicts of interest statement

The authors declare no conflict of interest with this work.

Data availability statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Funding

No funding sources supported the preparation of this manuscript.

References

[1]  Rimmer, A. (2020).  Covid-19: disproportionate impact on ethnic minority healthcare workers will be explored by government.  BMJ 369 m1562

[2]  Williams, DS; Costa, MM; Sutherland, C; Celliers, L; Scheffran, J. (2019).  Vulnerability of informal settlements in the context of rapid urbanization and climate change.  Environ Urban 31 : 157–76.

[3]  Ezeh, A; Oyebode, O; Satterthwaite, D; Chen, YF; Ndugwa, R; Sartori, J. (2017).  The health of people who live in slums 1: the history, geography, and sociology of slums and the health problems of people who live in slums.  Lancet 389 (10068) : 547–58.

[4]  Truelove, S; Abrahim, O; Altare, C; Lauer, SA; Grantz, KH; Azman, AS. (2020).  The potential impact of COVID-19 in refugee camps in Bangladesh and beyond: a modeling study.  PLoS Med 17 (6) e1003144

[5]  Gilman, RT; Mahroof-Shaffi, S; Harkensee, C; Chamberlain, AT. (2020).  Modelling interventions to control COVID-19 outbreaks in a refugee camp.  BMJ Glob Heal 5 (12) e003727

[6]  Raju, E; Ayeb-Karlsson, S. (2020).  COVID-19: how do you self-isolate in a refugee camp?.  Int J Public Health 65 (5) : 515–7.

[7]  Corburn, J; Vlahov, D; Mberu, B; Riley, L; Caiaffa, WT; Rashid, SF. (2020).  Slum health: arresting COVID-19 and improving well-being in urban informal settlements.  J Urban Heal 97 : 348–57.

[8]  Nix, E; Paulose, J; Shrubsole, C; Altamirano-Medina, H; Davies, M; Khosla, R. (2020).  Evaluating housing health hazards: prevalence, practices and priorities in Delhi’s informal settlements.  J Urban Heal 97 (4) : 502–18.

[9]  Pardeshi, P; Jadhav, B; Singh, R; Kapoor, N; Bardhan, R; Jana, A. (2020).  Association between architectural parameters and burden of tuberculosis in three resettlement colonies of M-East Ward, Mumbai, India.  Cities Heal 4 (3) : 303–20.

[10]  Parikh, P; Karim, YB; Paulose, J; Factor-Litvak, PP; Nix, E; Aisyah, DN. (2020).  COVID-19 and informal settlements – implications for water, sanitation and health in India and Indonesia.  UCL Open Environ 2 (1) : 1–5.

[11]  Campbell, AM. (2020).  An increasing risk of family violence during the Covid-19 pandemic: strengthening community collaborations to save lives.  Forensic Sci Int Rep 2 100089

[12]  Tusting, LS; Gething, PW; Gibson, HS; Greenwood, B; Knudsen, J; Lindsay, SW. (2020).  Housing and child health in sub-Saharan Africa: a cross-sectional analysis.  PLoS Med 17 (3) e1003055

[13]  World Health Organization. WHO Housing and Health Guidelines. Geneva: World Health Organisation.

[14]  Biswas, S. (2020).  How Asia’s biggest slum contained the coronavirus.  BBC News, June 23 2020 Accessed 21 February 2021 Available from: https://www.bbc.co.uk/news/world-asia-india-53133843 .

[15]  Biswas, S. (2020).  India coronavirus: More than half of Mumbai slum-dwellers had Covid-19.  BBC News, July 29 2020 Accessed 21 February 2021 Available from: https://www.bbc.co.uk/news/world-asia-india-53576653 .

[16]  Safi, M. (2021).  ‘We are not special’: how triumphalism led India to Covid-19 disaster.  The Guardian, April 29 2021 Accessed 26 May 2022 Available from: https://www.theguardian.com/world/2021/apr/29/we-are-not-special-how-triumphalism-led-india-to-covid-19-disaster .

 Open peer review from Anwesha Dutta

Review

Review information

DOI:: 10.14293/S2199-1006.1.SOR-MED.AHF07C.v1.RPCAMG
License:
This work has been published open access under Creative Commons Attribution License CC BY 4.0 , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Conditions, terms of use and publishing policy can be found at www.scienceopen.com .

Keywords: Sanitation, health, and the environment , Sustainability in architecture and the built environment , Health , COVID-19, housing, informal settlements, health, vulnerability

Review text

trhe authors have addressed suggested comments and i recommend no other changes. this remains an important contribution.



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This review refers to round of peer review and may pertain to an earlier version of the document.

 Open peer review from Christian Harkensee

Review

Review information

DOI:: 10.14293/S2199-1006.1.SOR-MED.A3SM6J.v1.RQJESW
License:
This work has been published open access under Creative Commons Attribution License CC BY 4.0 , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Conditions, terms of use and publishing policy can be found at www.scienceopen.com .

Keywords: Sanitation, health, and the environment , Sustainability in architecture and the built environment , Health , COVID-19, housing, informal settlements, health, vulnerability

Review text

Dear Authors and Editor,

This paper touches indeed on a very relevant and under-recognized topic – how do people living in poor housing conditions prevent themselves from becoming infected with Covid-19?

This paper is well written and has already undergone a couple of reviews, with a number of points already well addressed. I feel I can only make some relatively minor suggestions here.

The focus on the building, and living conditions within, is enlightening and highlights the near impossibility for people to protect themselves from Covid-19. Nevertheless, it might be helpful to look a bit broader at the community level of informal settings. A study from a refugee camp setting in Bangladesh (Truelove et.al., https://doi.org/10.1371/journal.pmed.1003144 ) has pointed out that the crowded living conditions would favour a rapid spread of Covid. Another study from the Moria refugee camp on Lesvos, Greece (Gilman et.al., http://dx.doi.org/10.1136/bmjgh-2020-003727 ) not only came to the same conclusions, but provided epidemiological modelling of a number of interventions to ‘flatten the curve’. Face masks and hygiene measures, if introduced early and with high adherence could have an impact. However, the potentially most effective measures included sectoring of the camp (with prevention of interaction between sectors, dedicating facilities such as toilets and washing facilities to sectors) and elimination and de-centralization of central convergence points (e.g. food distribution lines). This could potentially be an additional strategy in settings such as Mumbai.

Authors may explore sustainable housing designs, providing ventilation and natural light, in a bit more detail – perhaps providing some references to this. There is a number of good examples of this in South-East Asia.

Finally, authors may review the section that includes the lay media references 12 and 13, commenting on Covid-19 spread in India. Since this paper was published it became apparent that scientists and the Indian Government may have misjudged the level of herd immunity in India  ( https://www.theguardian.com/world/2021/apr/29/we-are-not-special-how-triumphalism-led-india-to-covid-19-disaster ).



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This review refers to round of peer review and may pertain to an earlier version of the document.

 Open peer review from UCL Open: Environment Editorial Office

Review

Review information

DOI:: 10.14293/S2199-1006.1.SOR-MED.AYB8J2.v1.RNMTAC
License:
This work has been published open access under Creative Commons Attribution License CC BY 4.0 , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Conditions, terms of use and publishing policy can be found at www.scienceopen.com .

Keywords: Sanitation, health, and the environment , Sustainability in architecture and the built environment , Health , COVID-19, housing, informal settlements, health, vulnerability

Review text

This review report is posted on behalf of Istiakh Ahmed.

This paper has articulated the issue quite well with proper explanation. Housing in informal settlements have always been an important issue to understand liveability of its dwellers. While I do not have any major comments for this paper, but a small point, which I believe will help us to understand the problem clearly and will make the argument strong.

  1. Speaking of Covid19, its safety practices are one important issue that also determine its contamination. Government, NGOs and all other relevant agencies are working to make sure that people follow the hygiene practices. However, poor housing condition and all the mentioned characteristics of the informal settlement housing, it becomes very difficult to maintain those practices. E.g. washing hands frequently is considered as one of the most effective measures for COVID19 but that would require for a dweller to go to the public water station which makes it more dangerous. Similar issues can be explored a little bit to understand how housing pattern/condition are also shaping people’s behavior and how that is effecting COVID19 contamination.


Note:
This review refers to round of peer review and may pertain to an earlier version of the document.

 Open peer review from Anwesha Dutta

Review

Review information

DOI:: 10.14293/S2199-1006.1.SOR-MED.AUKG3E.v1.RIXVUI
License:
This work has been published open access under Creative Commons Attribution License CC BY 4.0 , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Conditions, terms of use and publishing policy can be found at www.scienceopen.com .

Keywords: Sanitation, health, and the environment , Sustainability in architecture and the built environment , Health , COVID-19, housing, informal settlements, health, vulnerability

Review text

This is a very timely and important article that highlights the need to focus on informal housing and settlements which is essential in mitigating risks posed by COVID-19. The authors draw on their earlier work in India to showcase the abysmal conditions of these settlements which are characterized by poor ventilation, inadequate indoor and outdoor hygiene, absence of toilets, and crowding. These conditions, while increasing the levels of existing chronic diseases, also heightens the risk  of severe outcomes posed by COVID-19. Housing inadequacies are also directly linked to access to health services. Presenting health inequalities, often worse for women and children. Such housing conditions further increases exposure to infectious diseases, environmental pollution, while limiting a healthy lifestyle, and compromising general immunity.

Moreover, inadequate housing also poses restrictions in imposition of COVID-19 mitigation measures like social distancing, given the small size of households and often inter-generational; and makes recommendations like stay and work at home futile. Given that most residents are also dependent on community facilities to access toilets and water, physical distancing becomes impossible. The authors provide a comprehensive account of existing inadequacies both in terms of design, construction and architecture of housing facilities as well as the vulnerabilities these bring to fore for those residing in these settlements. The pandemic has indeed brought to fore housing inequalities and the risk of exposure to COVID-19 due to these inadequacies, which in turn does not allow compliance to recommended prevention measures- exposing a mismatch between recommendations and existing conditions on the ground.

While the authors sound out both immediate and long term recommendations to improve housing conditions and thereby reduce health inequalities, I believe, the authors could also benefit by highlighting some of the slightly success stories of COVID-19 management, particularly from Dharavi in Mumbai. Without undermining the long term suggestions for improvement, the case of Dharavi highlights the innovative ways that can be put in place by authorities, community and grassroots health workers to make the best out of existing resources and facilities. Also important are setting up of mobile testing clinics for early detection, thorough contact tracing and linkages to health care centers. Additionally, strengthening of local urban bodies through decentralization and provision of adequate social security and insurance (in current times), is essential. The article could also benefit from some statistics on informal settlements worldwide, how many people live in these settlements, income disparity etc.

To reiterate,  addressing housing deficiencies is mandatory in tackling the pandemic. Governments globally should take up the challenge now, since COVID-19 is not and will not be the last event of a zoonosis to impact the world.



Note:
This review refers to round of peer review and may pertain to an earlier version of the document.