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

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

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 ).

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.

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.