Introduction
The COVID-19 pandemic tragically continues to surge in India. The strict lockdown protocols may have stunted the transmission of the disease in some parts of the country, but the coronavirus continues to spread, particularly in cities with large, dense populations and major economic activity. Social distancing is almost impossible to practice in densely populated areas such as slums, where residents live in congested spaces with poor water, sanitation, and hygiene (WASH) facilities and practices, and shared public amenities. Thus, several of India’s slums are major hotspots for the virus.[1]
Further, the majority of slum residents are informal day-wage laborers and migrant workers who have lost their livelihoods through the pandemic and the lockdown—and become more vulnerable to the disease because of food insecurity and limited transport options. The extended lockdown and related COVID-19 response measures have adversely impacted other critical health needs and health determining factors. For example, patients with hypertension, cancer, or tuberculosis have been unable to access their medication or treatment.
In other pandemics, such as Ebola in West Africa or SARS in Asia, interventions that adopted a community-centric lens were more successful than others in driving sustainable impact. Studies revealed that crisis preparedness and response is not effective without the participation of vulnerable communities. When involved in the mitigation process, the communities’ “confidence, capacities, and coping mechanisms develop in an upward spiral,”[2] and they are more accepting of and amenable to remedial initiatives and approaches. For example, at the height of the Ebola crisis in Sierra Leone, fears and misconceptions existed about Community Care Centers (CCCs)—government facilities set up with UNICEF’s support—which led to them not being utilized to capacity. When additional CCCs were set up, the government consulted community leaders and influencers through the entire process of site selection, construction, and management of care, support and nutritional services. A social mobilizer interviewed as part of a related study noted, “Now the scenario has changed. The communities are so mobilized that people want to access CCCs, treat their loved ones early, and get more information on how they can protect their families from Ebola.”[3]
Beyond an epidemic context, the World Health Organization’s ENGAGE-TB approach similarly aims to integrate community-based tuberculosis (TB) diagnosis, treatment and management into the programs of nongovernmental organizations (NGOs). The approach, initially implemented in the Democratic Republic of the Congo, Ethiopia, Kenya, South Africa, and the United Republic of Tanzania, resulted in an increased utilization of TB care facilities, and increased disease notification rates.
Policymakers in India have recognized the important role of communities as part of a health crisis strategy. The National Health Policy 2017 calls for “close collaboration with local self-government and community-based organizations”[4] as well as “an army of community members trained as first responders for accidents and disasters.” The Disaster Management Act, 2005, under which the pandemic is being managed in India, also refers to the importance of community engagement.[5]
This rapid study explores how different community engagement models have played out in the context of the COVID-19 crisis in the major slums of Mumbai. We highlight why community involvement in slums is critical to the COVID-19 response and describe activities where communities have been engaged. We then synthesize the prevalent models for community engagement and assess the factors for replicating and scaling them in the slums of Mumbai and beyond, both to tackle the pandemic and to build community resilience for future pandemics or other physical, social, and economic shocks and stresses.[6]
In this report, we hope to inform policymakers, public health officials, funders, and civil society organizations about viable, large-scale community engagement models as an approach to sustainably address the pandemic, other infectious diseases, and wider health needs in slums and other densely populated low-income settlements.
We find that solutions specific to and respectful of the local slum context are more likely to institutionalize durable measures to prevent and control COVID-19. Our stakeholder interviews suggest that conventional top-down approaches will only have limited or short-lived success in tackling the pandemic in India’s slums, given their unique structural and demographic make-up. Community engagement approaches can have a broader and more lasting impact if they are part of a carefully planned disease response strategy where some elements of disease control are centralized, and others grounded in localized, community-driven measures.
Disproportionate impact of COVID-19 in the slums of Mumbai
Slums are a universal concept but take on a local character in different nations and their cities. The government of India defines slums[7] as “residential areas where dwellings are in any respect unfit for human habitation by reasons of dilapidation, overcrowding, faulty designs of buildings, narrowness or faulty arrangement of streets, lack of ventilation, light or sanitation facilities, or any combination of these factors which are detrimental to safety and health.”[8] Slums are common in India’s cities, constituting 24 percent of the urban population (100 million people)[9] nationwide;[10] in Greater Mumbai, they make up a sizeable 42 percent of the population (12.4 million people).[11]
Poor living conditions have made urban slums COVID-19 hotspots. Some estimates suggest that the population density of large slums in Mumbai, such as in Dharavi, is as high as 220,000 people per square kilometer.[12] Access to water and sanitation is a challenge; and as many as 78 percent of toilets in slums lack a reliable water supply.[13] Each year, 30-60 percent of households in Mumbai’s non-notified slums[14] (those not registered by the government) suffer from waterborne diseases because they have no access to the city’s central chlorinated water supply.[15] Moreover, congested slum residences are poorly ventilated and trap heat, so families, averaging 8-10 people, living together indoors for extended periods, are prone to falling sick.[16]
The impact of COVID-19 has therefore been disproportionately felt in India’s slums. On April 14, 2020, 31 percent of Mumbai’s containment zones—the areas most affected and hence under strict lockdown—were in slums; by May 11, 2020, this number had risen to 57 percent,[17] and by late June, it was closer to 96 percent.[18] A large portion of the slums’ residents also suffer from chronic illnesses such as respiratory infections, cancer, diabetes, and cardiovascular diseases, which increase their risk of mortality due to COVID-19.[19] A survey conducted by the Brihanmumbai Municipal Corporation (BMC)[20] at the end of April 2020 found that out of the surveyed 31,000 citizens—mainly in slums—over 4,000 senior citizens had such comorbidities.[21]
