Crowding has consequences: Prevention and management of COVID-19 in informal urban settlements

Abstract

COVID-19 spreads via aerosols, droplets, fomites and faeces. The built environment that facilitates crowding increases exposure and hence transmission of COVID-19 as evidenced by outbreaks in both cool-dry and hot-humid climates, such as in the US prison system and dormitories in Singapore, respectively. This paper explores how the built environment influences crowding and COVID-19 transmission, focusing on informal urban settlements (slums). We propose policy and practice changes that could reduce COVID-19 transmission. There are several issues on how COVID-19 affects informal urban settlements. Slum populations tend to be younger than the overall population. Lower numbers of older people lessen the morbidity and mortality of the pandemic in slum areas. Second, many slum populations are highly mobile. By returning to their ancestral villages residents can avoid the risks of overcrowding and reduce the population density in a given area but may spread COVID-19 to other areas. Third, detection and registration of COVID-19 cases depends on patients presenting to health care providers. If the risk of visiting a health care centre outweighs the potential benefits patients may prefer not to seek treatment. The control and prevention of COVID-19 in informal urban settlements starts with organizing community infrastructure for diagnosis and treatment and assuring that basic needs (food, water, sanitation, health care and public transport) are met during quarantine. Next, community members at highest risk need to be identified and protected. Low-income, informal settlements need to be recognized as a reservoir and source for persistent transmission. Solutions to overcrowding must be developed for this and future pandemics. In view of the constant risk that slums present to the entire population decisive steps need to be taken to rehabilitate and improve informal settlements, while avoiding stigmatization.

Keywords: Built environment; COVID-19; Crowding; Informal settlements; SARS-CoV-2; Slums.

Fig. 1

Comparison of average floor space as living area (in square meters) per person in different countries/territories. Reported average floor space (blue) minimum suggested floor space by different standards (red). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 2

Urban densities (person/km2).

Fig. 3

Demographic differences in the population structures of Kenya and Italy. Kenya has a broad base of young people while in Italy a large proportion is over of the population is over 50 years and thus at an increased risk for COVID-19 with poor outcome compared to Kenya. The y-axis indicates the percentage to the male and female population respectively. (data source PopulationPyramid.net ⁴²).

Fig. 4

A comparison of country and slum-area population structures. The overall national population structure (e.g. Kenya, Bangladesh)42is not representative for slum populations which tend to be younger (Kenya 44and Bangladesh 45) and predominantly male (Kenya 44only).