Key messages:
- The current COVID-19 pandemic amplifies existing humanitarian and development challenges, including those relating to housing.
- Shelter practitioners need to be aware of the immediate and long-term impacts of COVID-19, including the economic impact on renters and marginalised groups and should address these risks as best they can during the peak of the crisis.
- Immediate risk mitigation should include addressing overcrowding, poor ventilation and access to sanitation and hygiene facilities and will require close coordination with the WASH and health sectors.
- The pandemic highlights how poor-quality housing and settlement planning increase the risk of communicable diseases and exacerbate some non-communicable diseases. There is a need for further research on the potential beneficial health impacts of humanitarian shelter responses.
_____________________________________________________________________
“In addition
to providing protection from weather, shelter is necessary to promote health,
support family and community life, and provide dignity, security and access to
livelihoods”[1]
The current
COVID-19 pandemic provides a timely opportunity to re-examine the relationship
between shelter and health issues and to consider what actions the Shelter Sector
should take during the current crisis and in the longer term. This blog post
addresses the following questions, whilst also acknowledging the limitations to
our knowledge of the future progress of the pandemic:
●
What is the relative scale of
different risks to life and wellbeing, particularly for children, that are
connected to shelter and settlements?
●
How does the risk of COVID-19
compare with these other risks and how contextual is this risk?
●
How should shelter programming be
adapted in the current pandemic situation and in the future?
Links between shelter and health
Globally, in the
development and public/environmental health fields, there is increasing
awareness of the relationships between housing and health. The World Health
Organisation’s Housing and Health Guidelines[2]
note that “poor housing conditions are one of the mechanisms through which
social and environmental inequality translates into health inequality, which
further affects quality of life and well-being.” The Global Shelter Cluster
similarly recognises the huge numbers globally affected by health issues that
are at least in part related to shelter and settlement conditions.[3]
Shelter-related challenges to health worldwide include overcrowding, indoor air
pollution and inadequate water and sanitation facilities, both within the home
and wider settlements. These challenges link directly to many of the causes of
mortality and morbidity; they are exacerbated in humanitarian settings where
shelters are often at high density. Whilst overcrowding does not kill people
directly, it is a risk factor for the spread of infectious diseases such as TB
and COVID-19. Shelter-related health challenges are linked to a high proportion
of global deaths, as highlighted in data analysed by the Global Burden of
Disease[4] (see
following figure).
Globally the
majority of deaths are caused by non-communicable diseases. However, this does
not hold true in low-income settings where communicable diseases account for
the majority of deaths. There are significant geographical variations in causes
of mortality and morbidity and related burden of disease figures. For example,
most worldwide deaths from lower respiratory infections such as pneumonia occur
in Sub-Saharan Africa and SE Asia; the concentration of malaria deaths are to
be found in sub-Saharan Africa where, in Uganda, there is significant evidence
to suggest high incidences of malaria in children could be associated with
housing quality.[5] Many
health risks require local analysis, but it is true to say that many
communicable and non-communicable diseases already disproportionately impact
the poorest and most vulnerable communities worldwide.
The possible impacts of COVID-19 - so much is unknown
Even in the UK, one
of the richest countries in the world, COVID-19 and the actions to mitigate its
spread have highlighted existing inequalities in housing and their
repercussions for both physical and mental health.[6]
People living in the private rented sector in the UK are particularly at risk
from poor quality, overcrowded and precarious housing and the current crisis
has brought this into focus. In low income settings around the world,
particularly in displacement camps[7] and urban
slums[8], the
spread of COVID-19 is also likely to be exacerbated by crowded conditions and
poor access to sanitation and hygiene. There are serious humanitarian
implications that must be addressed by humanitarian actors.
At the time of
writing, there are over 2.1 million known cases and over 146,000 confirmed
deaths globally.[9] However,
there are no reliable data on the total number of cases – solely the number
confirmed by tests – and the pattern of testing is very uneven. Case fatality
rates are already varied, with many factors such as age structure, social
housing norms, population density, patterns of underlying health conditions and
capacity of healthcare systems certain to have an effect on eventual fatality
rates in different settings. Projections of total infections, deaths and their
geographic spread over the next months or years are problematic. It is
therefore highly speculative and possibly unhelpful to attempt to compare
COVID-19 with other causes of death. Nevertheless, the section below aims to
explore the relative scale of health risks to children in order to suggest that
COVID-19 is one risk among many that need to be considered by shelter
practitioners. The pandemic is exposing and exacerbating wider intersectional
and class issues - people around the world living in overcrowded homes and
settlements are at greater risk from COVID as well as multitude of other health
risks, and have little power to influence improvements to their living
conditions.
Children, COVID-19 and other health risks
Women, children and
those living with disabilities are particularly vulnerable to housing-related
health risks as they are frequently more confined to their dwellings.
Inadequate housing has particular impacts on children’s health:
“Children are
more vulnerable to indoor exposures due to their behaviour, the lower capacity
of their immune systems, and the fact that they have, relative to their body
weight, a much higher intake of pollutants than adults”[10]
While the total number of annual child deaths has more than halved from
11.8 million in 1990 to 5.4 million in 2017, the major causes of child deaths
have largely remained the same. 15,000 deaths per day of children under 5
globally rarely makes headlines: yet a large percentage of the most common
causes of death for this age group – pneumonia, diarrhoea and malaria – are
preventable by interventions known to reduce environmental risks within the
home, such as access to safe water, adequate vector control and clean cooking
fuels. Pneumonia alone, linked strongly to indoor air pollution as well as
other risk factors such as malnutrition, killed over 800,000 children in 2017.
Diarrhoea killed over 500,000 and malaria over 350,000. In countries with low
socio-economic indices, the proportion of child deaths that are linked to
unhealthy living conditions is particularly high, as shown in the figure below[11].
Unlike malaria,
where 57% of global deaths are in children under 5, current data trends suggest
older people are at a higher risk from COVID-19, with
over 95% of deaths occurring in those older than 60 years[12];
the case fatality rate for children is very low. It appears that for this demographic group at least,
COVID-19 will present a lower direct risk than the existing environmental risks
they are exposed to, including those related to their shelter. However, they
will still be acutely affected by the socio-economic impacts of the virus, for
example the loss of a primary caregiver, loss of family income or increased
risks of abuse.[13]
Responses to COVID-19 may not directly address the
current and pre-existing health risks to children that are responsible for
significantly higher death rates in low-income settings. However, improvement
in living conditions through less overcrowding and
increased access to hygiene and sanitation facilities, both within the
home and wider settlement, would mitigate many environmental risks and help
address some of the greatest causes of deaths in children.
The humanitarian shelter response to the current COVID-19
pandemic
Arguably,
humanitarians should evaluate COVID-19 as a hazard like any other, with its own
risk parameters, expected outcomes and impacts to be weighed against costs of
mitigation options.[14] As it is a
highly infectious disease whose spread and impact can be linked in part to
housing, the Shelter Sector needs to consider its role in mitigating these
impacts - both now with immediate effect, and also in future policy and
practice. In low-income countries and humanitarian settings, COVID-19 is a new
and currently all-consuming health threat to add to those risks already endemic
in so many multi-hazard environments. While in the UK, it can be accurately
described as unprecedented, for many countries it is one additional risk to the
many already facing the population. Governments, institutions and communities
are already grappling with the need to evaluate the relative risks of disease,
climate change and natural hazards and to prepare for and mitigate them.
Between 2030 and 2050, climate change is expected to cause approximately
250,000 additional deaths per year, from malnutrition, malaria, diarrhoea and
heat stress alone[15]. Negative
social and economic impacts of climate change are also likely to be worse in
poorest communities in all parts of the world.
Where the Shelter Sector
has on-going responses, there is an imperative to implement any practice that
can reduce the spread and impact of COVID-19. What those measures may be will
depend on the context and the availability of resources and land. The Global
Shelter Cluster has already published its COVID-19 response plan, identifying five
ways that on-going Shelter and Settlements programmes can help to minimise the
spread of the virus. These include reducing overcrowding and density of
settlements where possible, planning and building isolation areas and medical
facilities and distributing humanitarian assistance (including NFIs) in ways
which avoid spreading the virus.[16] Other responses could include the decongestion of
camps, an increase in covered living space and replanning of areas where people
gather. In reality, the potential for making a significant difference within a
meaningful timeframe, in established camps and settlements, is likely to be
very limited. The significance of any mitigating action should be considered in
collaboration with health experts. For example, can living space be increased
sufficiently to ensure ‘social distancing’? If not, then is the budget best
spent on a more relevant measure such as targeting the most vulnerable, or
improving household level washing facilities? To achieve well-informed,
‘better’ shelter responses after disasters and conflict, there is a need for
cross-sectoral/cluster coordination and an interdisciplinary lens. The way that
Shelter interacts with Health and WASH sectors is of particular relevance in
the current pandemic.
Longer-term responses by the humanitarian sector to
unhealthy housing
What seems, from
the viewpoint of this global crisis, to be beyond debate is that much greater
consideration needs to be given to the connections between adequate housing and
good health. Substandard housing, with overcrowding and poor water and
sanitation, will exacerbate the spread of COVID-19 with fatal consequences.
This is nothing new: poor indoor air quality, contaminated water and inadequate
vector control are all endemic housing-related risk factors causing millions of
fatalities each year and that also have extensive social and economic
consequences. While the ability of the humanitarian Shelter Sector to have a
positive impact on the spread of the current pandemic may be somewhat limited,
it is nonetheless crystal clear that humanitarian crises pose an opportunity to
ensure that ‘healthy housing’ is an integral part of future shelter responses.
It is well-accepted that there is a need for research into the wider impacts of
shelter programming[17];
the current COVID crisis casts a spotlight, if ever it was needed, on to the
imperative of a healthy home. Good humanitarian shelter programming, that holds
strong to this principle, can have a beneficial impact on the health of
everyone, but especially children, women and the elderly.
With thanks to Bill Flinn and Beth Simons for their contributions to this article.
This research was made possible by funding from the GCFR Translations Award (grant EP/T015160/1) for the Self-recovery from Humanitarian Crisis project.
This research was made possible by funding from the GCFR Translations Award (grant EP/T015160/1) for the Self-recovery from Humanitarian Crisis project.
[1]Sphere Association (2018) The Sphere Handbook: Humanitarian Charter and Minimum Standards in
Humanitarian Response, fourth edition, Geneva, Switzerland p240
[3] Flinn, B., Schofield, H. and Miranda Morel,
L. (2017) ‘The Case for Self-Recovery’ Forced Migration Review 55 pp 12-14.
[5] Snyman, K., Mwangwa, F., Bigira, V., Kapisi, J., Clark, T.
D., Osterbauer, B., Greenhouse, B., Sturrock, H., Gosling, R., Liu, J., &
Dorsey, G. (2015). Poor housing construction associated with increased malaria
incidence in a cohort of young Ugandan children. The American journal of tropical medicine
and hygiene, 92(6), 1207–1213.
[6] Clair, A. ‘Homes, health, and COVID-19: how
poor housing adds to the hardship of the coronavirus crisis’ 2/4/2020 ESRC
Research Centre for Micro-Social Change, Institute for Social and Economic
Research, University of Essex http://www.smf.co.uk/homes-health-and-covid-19-how-poor-housing-adds-to-the-hardship-of-the-coronavirus-crisis/
[8] Ellis-Petersen, H. and Azizur Rahman, S.
(2020) ‘'We are very afraid': scramble
to contain coronavirus in Mumbai slum’ The
Guardian 7th April 2020 https://www.theguardian.com/world/2020/apr/07/we-are-very-afraid-scramble-contain-coronavirus-mumbai-slum-dharavi
[10] WHO (2017) Inheriting a sustainable world? Atlas on children’s health and the
environment. Geneva
[11] Richie and Roser (2020) "Causes of
Death". Published online at OurWorldInData.org. Retrieved from:
'https://ourworldindata.org/causes-of-death' [Online Resource]
[12]http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/statements/statement-older-people-are-at-highest-risk-from-covid-19,-but-all-must-act-to-prevent-community-spread
[13] The Alliance for Child
Protection in Humanitarian Action, Technical Note: Protection of Children
during the Coronavirus Pandemic, Version 1, March 2019
[14] Shepherd-Barron, J. (2020) ‘Disaster
Economics. COVID19: Is the gain worth the pain?’ Aid Essentials 30/3/2020 https://www.aidessentials.org/category/disaster-management/disaster-economics/#_ftn2
[17] Kelling, F. (2020) The
Wider Impacts of Humanitarian Shelter and Settlements Assistance. InterAction.
No comments:
Post a Comment