COVID-19 experience among slum dwellers in Nairobi: A double tragedy or useful lesson for public health reforms?

The experience of COVID-19 and government response by slum dwellers in Nairobi

The rapid spread of the Corona-virus has raised concerns over the impact this pandemic will have on countries with less developed health systems. With many countries in Sub Saharan Africa still in the process of developing their health sector, some scholars have predicted that Africa will become the epicenter of the disease. Despite such worrying predictions, the direct impact of the disease has been only been felt in five four countries (South Africa, Egypt, Nigeria, Ghana, and Algeria) which constitute more than 60% of the confirmed cases in the continent. However, in Kenya, it is the indirect negative impact of this pandemic that seems to raise more concern. More so, people living in crowded urban settlements who are now facing new socio -economic and health challenges. These new challenges are worsening the already existing socio-economic problems. Nairobi has more than 100 informal settlements, including the largest slum in the continent. These crowded settlements occupy only 5 percent of the total residential area in the city, and more than 4 million people (65% of Nairobi’s population) call these slums home (UN-Habitat, 2019). Despite being a significant portion of the population, slum dwellers have historically been marginalized in government economic and health policies, exposing them to more severe consequences in the wake of the COVID-19 outbreak. The concern over the vulnerability of slum dwellers is not only limited to the spread of the virus, which would be elevated due to the high population density in the slum areas, but also the negative direct effects such as anxiety and depression that rise as a result of the uncertainty over their jobs and income. The COVID-19 taskforce approach reflects other previous inactions by the government when dealing with issues that affect people living in low-income areas.

The political economy of slums in Nairobi has continued to hurt the poor, unskilled migrants who move into the city and end up in the informal areas for decades. Lack of planning and investment, and neglect by the government, have left informal areas such as Kibera, Mathare, Korokocho, Mukuru, Soweto, and Kawangware with inadequate health facilities, lack of proper housing and sanitation, insufficient water and electricity, and an inadequate number of schools, and a depleted economic infrastructure. In the wake of the COVID-19 pandemic, residents of these informal areas have found themselves experiencing a double tragedy: on one hand, the threat posed by the rapid spread of the virus could spell a disaster in the slums given that a majority of residents lack health insurance coverage, lack of proper sanitation within the slums, and high population density making it difficult to implement practices such as social distance. On the other hand, measures being implemented by the government to curb the spread of the disease have disrupted activities in the informal sector where many slum dwellers depend on their daily wages. This has turned the blanket policies, characterized by curfews, partial lockdown, and ‘social distancing’ that the government of Kenya has adopted, appear to be a cruel joke for slum dwellers as they do not address the main needs for survival of people living in slums. The seemingly blatant oversight of the unique challenges people living in informal areas face is concerning and worth reflecting upon going forward. Indeed the impact on lives, the cost, and the technical capacity needed to respond to a potential mass spread of the virus as seen in countries like the United States, Spain, and Italy is beyond the reach of Kenya and many developing countries. This means that any preventive response by the government should go beyond blanket measures and interrogate different circumstances that could undermine its efforts. The extraordinary challenges faced by people living in urban informal settlements during the corona -virus pandemic indeed calls for the use of skills and support of social workers.

As observed, despite the curfew and lockdown policies that have forced slum dwellers to spend more time in crowded, run-down, single-roomed, low-quality shanties where several people are forced to share even at times overflowing toilets and bathrooms, the number of COVID-19-positive cases in the country has steadily increased, begging the question as to whether these measures are effective. In addition, multi-generational family members end up crumpled in the tiny homes, posing a serious threat to vulnerable children and senior citizens. In addition given the lack of accurate data on the slum residents and unrestricted entry and exit in these areas, surveillance which has been a centerpiece for countries (Macau and South Korea) that have been able to flatten the COVID-19 curve through contact tracing will be nearly impossible to attain in Nairobi slums should the disease break out. Social workers can play a crucial role in producing data and surveillance within the informal settlements. Economically, the majority of the slum dwellers who are employed work as casual laborers without health insurance coverage or pension. Those who are self-employed engage in low-paying activities such as waste collection, recycling, and street vending which pose a high health risk. Despite the meager wages, their dependence on these jobs as a source of livelihood has been disrupted. However, even with the cash transfer package announced by the government, the amount can hardly cover half a million people, leaving a majority of 35 percent of Kenyans who live below the national set poverty line unattended (Kenya National Bureau of Statistics [KE], 2018). This can cause mental and psychological stress which needs social work intervention.

Policy recommendations

Despite the negative impact the disease has had globally, it should serve as an eye-opener for governments, especially regarding the way people living in informal settlements are treated. This can be done in two phases (short term and long term). In the short term, the government needs to ensure its preventive measures are effective and relevant to the challenges facing people from different socio-political and economic backgrounds. These could include a slum-specific policy document outlining socio-economic relief measures that are uniquely meant for the slum dwellers. For example, given that direct tax reductions can have less impact on the informal sector, the government could establish another pro-poor subsidy that will directly benefit people in the slums. Efforts such as providing e-food and e-medical vouchers, leveraging on technology and community health workers to reach out to people deep inside the slums, and mobile clinics with essential stockpiles can be strategically positioned in slums to make up for the few health facilities. Social workers can play a crucial role in dealing with the growing number of gender-based violence cases. Equally, they can offer counseling and advise to victims of sexual harassment and abuse, including the alarming number of teenagers who have become pregnant during the lock-down period. These vulnerable groups may not be infected by the virus, but the conditions they find themselves as a result of the indirect consequences of the pandemic require a robust response from the government and other stakeholders. Urgent environmental rehabilitation by the National Youth Service and the military can help reduce the pollution in slums and support the establishment of temporary sanitation facilities. More importantly, apart from the national sensitization exercises, the messaging and communication avenues used to educate slum dwellers about the virus and its associated risks is critical. We live today in an era of fake news and misinformation, which at times affects how citizens react to the pandemic.

In the long run, the government could adopt some of the lessons from COVID-19 to offer long-term solutions. For example, given that slums occupy only 5 percent of the land area in Nairobi, a slum upgrade program could adopt cheaper technology to establish well-organized prefab houses with population limits in an area. By improving the living conditions of slumdwellers through these projects, many social, economic and health related issues will also be addressed. For example, well planned, low -cost housing initiatives will provide the residents of these areas better connection to sewer, water, and electricity systems. Also, the challenge that arises from difficulty to access the interior of slums especially during emergencies such as fire will also be solved as designated roads will provide fire engines and ambulances easy access. This is a robust plan but one that in the long run will not only uplift the standard of living for millions of Nairobi residents but also reduce over -crowding and ease monitoring as well as surveillance thus reducing the risk currently being experienced due to the coronavirus pandemic.

Second, also in the long term, the government could reform the national health insurance fund to allow people from all walks of life to access the coverage. The current and previous health schemes in Kenya did not fail due to the lack of resources, but corruption and poor strategies made millions of citizens miss out on this important program. Proper reforms in the health system will benefit low-income earners the most. Third is ensuring sustainable supply chains not only to the formal residential areas but also to informal areas. Slum dwellers are at times forced to buy expensive goods due to unreliable supply chains and artificial shortages. This includes fresh food and medical supplies, which are essential to the well-being of the people.

The government needs to engage social workers and their services more during and after the pandemic to improve the livelihood of people in the informal settlements. It is evident that dependence only on government resources during the pandemic will be catastrophic. Different stakeholders can address different issues that are emerging as a result of the pandemic. During the lockdown and the curfew, it is important that social workers be categorized as essential workers to allow them free movement so that they can offer the much-needed services to slum dwellers. The unique services social workers can offer will go a long way in helping people, especially vulnerable citizens, to cope with the pandemic. Indeed, from mental and emotional health to providing genuine information in an era of fake news, social workers’ input during such a crisis will be invaluable. Inadequate community safety and healthcare that slum dwellers are experiencing could also be better addressed if more social workers and not police are deployed.