Let everyone navigate their route with respect, empathy and responsibility.” – Poet Damien Barr

Social distancing is a crucial precautionary measure needed to halt the spread of the coronavirus but it is unlikely to be effective in Karachi’s urban slums where large families have no choice but to share small quarters. Besides physical space being scarce, citizens in informal settlements have poor access to clean water making another safeguard against the virus, handwashing, difficult to observe.

Estimates suggest that over half of the city’s population live in its approximately 700 informal settlements where cramped, unsanitary living conditions make community transmission of the virus more likely. 

“In relatively well-off areas of Karachi, citizens can comfortably keep themselves safe from the virus home,” says Dr Romaina Iqbal, an associate professor in the department of community health sciences at AKU. She is leading a project analysing barriers to healthcare in the urban slum of Azam Basti, southern Karachi, which lies on the outskirts of one of the city’s wealthiest areas, the Pakistan Defence Officers Housing Authority. 

 

“The affluent also have the financial means to withstand disruptions during the lockdown. But the urban poor are at risk of falling even deeper into poverty and ill health if they stay at home. Since they are significantly more likely to contract the disease and are more vulnerable to the consequences of a lockdown of essential services, policymakers must adopt a different approach in urban slums,” Dr Iqbal adds.

Through interviews with residents and health workers on issues such as access to testing and preventive health facilities, observance of lockdown measures and continuity of essential services, over a period of three weeks, researchers have suggested a range of interventions that can help keep residents of urban slums safe from COVID-19. 

Researchers found poor awareness of the importance of social distancing with many residents saying that it was common for children and adults to roam around the community and to gather in small groups. One interviewee noted that efforts to ensure ‘safe’ queueing, at least a meter apart, outside shops was also proving to be ineffective. In some cases, residents have had to sit in the streets due a lack of space at home but in the majority of cases people were not observing government guidelines.

Researchers found that television was the main source of information in the community and highlighted the need for broadcast campaigns to explain the importance of social distancing protocols and how to correctly observe them. They also suggested the development of pictorial handbooks that can help community health workers spread awareness in the area.

Private healthcare facilities remain open in Azam Basti but testing and care for complications from the virus is only available at larger hospitals in other parts of the city. While healthcare workers in local healthcare centres have arranged for personal protective equipment, very few patients are taking precautions such as wearing facemasks and gloves. Researchers also found very low awareness about telehealth initiatives with few respondents knowing that they could reach healthcare institutions through their cellphone.

Immunisation services and community health worker visits to households in Azam Basti have been disrupted during the lockdown. Interviewees noted that this has led to pregnant mothers missing appointments and children not receiving vaccinations.

 

While access to healthcare is a concern for those with ill relatives, poverty and ensuing food shortages is a much greater worry. Those reliant on daily wages lack savings to weather economic disruptions. They are struggling to purchase groceries and have become reliant on handouts by NGOs in the area. Interviewees also noted that better-off households were stocking up on supplies, worsening shortages in local markets.

 

None of the respondents had received help from the federal government’s poverty alleviation programme, Ehsaas, and worsening food security is making it difficult for residents to follow guidelines to stay at home.

Researchers highlighted the need to resume primary healthcare services and vaccination activity immediately and called for special food supply drives to be launched with a focus on households with pregnant women and under 5s.

Even though Azam Basti’s residents are aware of the need to keep their hands clean, unreliable water supplies represent a barrier to handwashing. Most residents found sanitisers to be unaffordable, however, they can buy soap for the home.

 

Researchers suggested that steps be taken to set up communal handwashing stations at regular intervals and mentioned the need to distribute soap in the community to ensure that this preventive measure against the virus can be followed.

 

“We face a higher risk of other public health hazards such as malnutrition and outbreaks of vaccine preventable diseases unless we scale up preventive healthcare services during the lockdown,” said Dr Narjis Rizvi, an associate professor in community health sciences at AKU and co-investigator of the project. “Residents of urban slums are especially vulnerable to the consequences of poverty and NGOs and public sector institutions must act now to reduce the threat of other public health crises in the coming months.”

 

The study is funded by UK Aid and the National Institute for Health Research and is being conducted in partnership with universities and research institutions in the UK, Bangladesh, Kenya and Nigeria. It is a four-year project led by the department of community health sciences at Aga Khan University.