CASE STUDY

COVID-19 VULNERABILITY IN INFORMAL SETTLEMENTS: A CASE STUDY OF AN URBAN IDP COMMUNITY IN JALALABAD, AFGHANISTAN1

KEY MESSAGES

• This brief presents a detailed case study of an IDP community in the eastern capital of Jalalabad, Afghanistan, to reveal complex vulnerability profiles of urban informal settlements to COVID-19. • Vulnerability is associated with crowded living conditions, low capacity WASH, insecure livelihoods, food insecurity and limited access to health, social and economic services. Low- income and female-headed households are most at risk. • In response, the brief recommends integrated, gender-sensitive responses to address the multi-dimensional risks associated with the pandemic, and to contribute to the long-term resilience of communities. Urban informal settlements and COVID-19 in Afghanistan

The SARS-CoV-2 pandemic2 has affected WASH and restricted access to health services millions of people across the globe as health (UN-Habitat 2020). Moreover, disease outbreaks systems have struggled to deal with the high in informal settlements may lead to rapid proportion of patients requiring hospitalisation, increases in caseload to overwhelm fragile health and in particular critical care admission (Zhou infrastructure and catalyse virus transmission et al. 2020). While the bulk of reporting has across cities and countries. As well as the focused on high- and middle-income countries direct health impacts, informal settlements where the outbreak has been concentrated, a are particularly vulnerable to secondary growing concern is how low-income countries socioeconomic impacts of the virus. Many with fragile health systems will respond to the work in the informal sector with low-income pandemic (Poole et al. 2020). In this context, and unstable incomes that can be disrupted by 40 years of protracted conflict has rendered lockdowns. A key concern in Afghanistan is food Afghanistan particularly vulnerable. The spread of insecurity: the WFP reports surging food prices as the disease is of immediate concern because of supply chains are disrupted due to the pandemic, the country’s porous border with global hotspot placing severe pressure on the most vulnerable Iran, where the WHO reports 80,000 cases and (OCHA 2020). 5,000 deaths to date (April 2020); indications are that unreported figures could be far higher. Although no comprehensive data exists, large Since Iran’s outbreak began in January 2020, the urban informal settlements are thought to exist IOM reports over 250,000 people have crossed across Afghanistan’s major cities. According the border from Iran into Afghanistan (IOM to IOM’s Displacement Tracking Matrix, there 2020), presenting severe transmission risks to the are around 4.2 million IDPs in Afghanistan, the Afghan population (Mousavi et al. 2020). At the majority displaced by conflict; in addition, there time of writing, Afghanistan’s Ministry of Public are a further 4 million returnees, repatriated Health (MoPH) has reported 10,582 confirmed mainly from Iran and Pakistan (IOM 2020). Many cases. However with limited testing capacity, true IDPs and returnees lack the resources to access numbers are likely to be far higher. In addition, secure land and housing, and live in challenging there are fewer than 2,000 isolation beds across conditions in urban informal settlements in large the entire country, and limited capacity for ICU cities. In the capital, Kabul, a recent survey by care, which could exacerbate death rates (Shah et UN-Habitat identified 54 settlements across the al. 2020). In late March, the Afghan government municipality. This group represents a significant implemented a lockdown to stem the spread of public health risk in the context of the COVID-19 SARS-CoV-2; it remains to be seen how effective pandemic. this will be in slowing the spread of the virus. This brief aims to aid the COVID-19 response In the fight against COVID-19, Afghanistan’s in Afghanistan by supporting evidence- large displaced population living in urban based emergency response interventions, and informal settlements are of particular concern. identifying longer-term support options to work The disease is highly contagious and spreads towards durable solutions for IDPs and returnees between humans with alarming efficiency in in informal settlements. It reports the results of areas with high population densities: it has a a total population survey of Surkh Dewall, an R0 transmission of rate estimated at 2-3, and informal settlement located near the eastern city a secondary attack rate of over 30 per cent of Jalalabad; from a total of 643 families residing (Wang et al. 2020). As a result, cities across in the settlement, 638 were surveyed in 2019 by the globe are on the front-line of the global UN-Habitat. The settlement was formed in 2015 pandemic. To date, there have been few empirical by a community displaced from their place of investigations of COVID-19 vulnerability in urban origin in Nangarhar province because of conflict informal settlements, although vulnerability between the Afghanistan branch of Islamic State to the virus in this population is thought to be and government forces. With a population of high because of overcrowding, low capacity approximately 350,000 Jalalabad is the fifth

2 COVID-19 vulnerability in informal settlements: a case study of an urban IDP community in Jalalabad, Afghanistan most populous city in Afghanistan and the the socioeconomic causes of vulnerability, largest city in the Eastern province of Nangarhar, highlighting the key issue of food insecurity. which borders Pakistan. The city includes large Finally policy recommendations for emergency populations of conflict-displaced IDPs, and response and durable solutions are provided, returnees from Pakistan, living in urban informal and a toolkit for assessing informal settlement settlements. Following this introduction, the brief vulnerability in Afghanistan is proposed. will assess the key public health risks associated with transmission of COVID-19 in Surkh Dewall, Public health risks of COVID-19 in urban informal settlements

In the absence of effective treatments or a Overcrowding, and multiple occupancy housing, vaccine for SARS-CoV-2, the global defence is a key risk of COVID-19 transmission for the against the virus has centred on limiting population of Surkh Dewall. On average, over transmission. This strategy is particularly 15 people reside in each dwelling, with the applicable to Afghanistan, where there are majority of households (92 per cent) living in very limited health facilities to treat COVID-19 single roomed mud-brick dwellings. There is also patients. The country already suffers from some a highly vulnerable five per cent of households of the poorest doctor per capita statistics in the residing in tents, accounting for a total of 30 region, and healthcare facilities typically provide families and over 150 people. This high number only basic care. For residents of Surkh Dewall, of people living in close proximity is alarming there is only one hospital with the capacity to because it has been known since January 2020 treat critical COVID-19 patients in Jalalabad, that the main spread of COVID-19 has occurred and their facilities for critical care would likely within households, driven by close contact and be quickly overwhelmed in an outbreak. In this prolonged exposure to infected respiratory context, the key public health response to limit droplets. The ability for people to adhere to impact of COVID-19 is to limit transmission of social distancing and to self-isolate, and thus the disease. However, the case of Surkh Dewall protect others in their household when exhibiting demonstrates the many challenges associated symptoms of COVID-19, is near impossible in with stemming the spread of the disease among such a context. populations of informal settlements.

© UN-Habitat Afghanistan

COVID-19 vulnerability in informal settlements: 3 a case study of an urban IDP community in Jalalabad, Afghanistan © UN-Habitat Afghanistan

Overcrowding synergises with low capacity WASH total of 56 families, and 325 individuals – report services to present additional transmission risks practicing open defecation; female-headed and for residents. Evidence has shown SARS-CoV-2 lower-income households are most likely to RNA to be present in faeces of over 50 per cent practice open defecation (Fig 1). The remainder of in-patients who are PCR throat swab positive of households used basic open latrines, which in China, and to remain present in stool past the also present high contamination risks, particularly point where patients start to be (nasopharyngeal) in the context of overcrowded housing. In such swab negative (Bonato, Dioscoridi, and conditions, anecdotal evidence suggests that Mutignani 2020). Inadequate wastewater women often limit water intake and limit the management, therefore, is an important potential frequency of urination and defecation. These route of transmission. In this context, residents practices can lead to physical and psychological of Surkh Dewall suffer low capacity WASH stress, leading to adverse health impacts that systems, presenting severe transmission risks. could complicate COVID-19 and result in worse Nine per cent of respondents – accounting for a health outcomes.

       

                 

Fig 1: Households practicing open defecation by income group and gender of household head (per cent)

4 COVID-19 vulnerability in informal settlements: a case study of an urban IDP community in Jalalabad, Afghanistan In addition to issues with wastewater, the affecting all residents is access to clean water. settlement is not served by municipal solid waste Residents report that the water from available disposal services. In this context, low capacity boreholes located in the settlement is dirty and solid waste management has been shown to unfit for consumption. As a result, residents pose an increased risk to COVID-19 transmission purchase clean water from tankers, which has led associated with the incorrect disposal of infected to water rationing and associated hygiene risks material (Mol and Caldas 2020). that heighten COVID-19 transmission. Given the importance of sanitary environments to prevent the spread of COVID-19, a key issue Socioeconomic dynamics of COVID-19 vulnerability

The precarious livelihood characteristics of Low and insecure incomes constrain residents’ residents of Surkh Dewall render them vulnerable ability to take measures to prevent COVID-19 to COVID-19 transmission, and the secondary transmission, such as purchasing personal socioeconomic impacts of the disease. A key issue hygiene products or staying at home and relates to low and irregular income. The majority self-isolating when COVID-19 symptomatic. of households work in the informal sector as Households also have limited resources to unskilled labourers (around 80 per cent), with meet the costs associated with healthcare and the remainder earning a living as street vendors. lost income if a family member becomes ill. The majority (over 87 per cent) of respondents In addition, the informal livelihood activities report a family income of less than 5,000 AFG reported by residents (unskilled labourers and on average per month (around 64 USD), which street vendors) are located in public space and equates to around 1,000 AFG per month (around involve travel, rendering residents’ income 13 USD), or less than 0.5 USD per person per at-risk from government-enforced COVID-19 day; these figures are significantly below the lockdowns. In this context, the precarcity of average for Afghanistan.3 A large proportion informal livelihoods means that the consequences of respondents suffer extremely low incomes. of the health and economic shocks associated Around 30 per cent reported a family income of with COVID-19 are particularly severe. In less than 1,000 AFG a month (13 USD), equating addition, 82 per cent of patients testing positive to less than 2.25 USD or around 0.08 USD per for SARS-CoV-2 are between 20-59 years of person per day. Female-headed households were age (OCHA 2020); hence, those suffering with most often in the lowest income bracket, with symptoms are likely to be household earners, over 50 per cent reporting a family income of less exerting further pressure on vulnerable residents. than 1,000 AFG a month, and were least likely to Female-headed households are most at risk be in the highest income bracket, with only four because they suffer lower incomes than their per cent (one family) reporting a monthly income male counterparts. over 5,000 AFG (Fig 2).

    

     

                  Fig 2: Proportion of households at different income brackets (per cent)

COVID-19 vulnerability in informal settlements: 5 a case study of an urban IDP community in Jalalabad, Afghanistan A key secondary impact of the COVID-19 for staple foods such as oils and cereals of up outbreak is food insecurity. In Surkh Dewall, 31.3 to 20 per cent (OCHA 2020). Increasing food per cent of respondents report insufficient food prices synergise with disruption to informal stocks during the past 7 days; those with lower livelihoods to present severe risks for residents’ income and female-headed households suffer health: as nutrition is a key determinant of more severe food insecurity (Fig 3). Residents health, there is the risk that worsening food also report unbalanced diets, which typically security will negatively impact the mortality rates consist of cereals (usually bread), oil and fat and of COVID-19. In addition, lower incomes and sugar; on average vegetables and pulses are increased expenditure will present additional consumed less than 3 days a week, while meat, transmission and socioeconomic risks to fruit and dairy products are rarely consumed households, with low-income and female-handed (Fig 4). In this context, the WFP reports that families most affected. COVID-19 pandemic has caused price surges

                           

Fig 3: Households reporting food shortages one or more days per week by income and gender of household head (per cent)

               
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Fig 4: Average number of days food items consumed over past week

6 COVID-19 vulnerability in informal settlements: a case study of an urban IDP community in Jalalabad, Afghanistan Policy responses

This brief has highlighted the key points of 2. Strengthening socioeconomic resilience COVID-19 vulnerability that are present in Surkh and food security Dewall, and are likely present in IDP communities residing in urban informal settlements across The burden of health costs and restriction on Afghanistan. In response, the government is economic activities during the outbreak exert ramping up testing and critical care capacity, social and economic pressures on residents of however, meeting the likely future need will be a informal settlements. The majority of residents major challenge. Hence, in tandem to upgrading in Surkh Dewall work as unskilled labourers, national and municipal health infrastructure, rendering them vulnerable to economic shocks, this brief provides the following community- and stuck in a cycle of low paying and insecure level policy suggestions to increase resilience to work. In a context of food insecurity, reduced COVID-19. Suggestions are provided for short- incomes could have severe consequences for term emergency response, and to work towards residents’ health. durable solutions for long-term community Emergency response: The provision of resilience. unconditional cash transfers to residents of 1. Limiting COVID-19 transmission in urban informal settlements during the pandemic would informal settlements enable residents to purchase sufficient food and water. With 15 people per dwelling, overcrowding is perhaps the single biggest risk factor in Durable solution: Providing enhanced education relation to transmission in Surkh Dewall. This and training services linked to local livelihood is particularly the case for residents that reside opportunities would support the socioeconomic in tents. In this context, low-capacity WASH development of the settlement and residents. synergises with high population density to Implementing a cash-for-work settlement present severe transmission risks. upgrading programme – in tandem with education and training support – could address Emergency response: In terms of emergency this issue. response, items such as hygiene kits and Personal Protective Equipment (PPE) to limit transmission 3. Inter-agency, integrated and gender- are urgently required. Other priority housing, sensitive responses WASH and infrastructure investments include the To effectively address the multi-dimensional forms construction of public toilets to meet the need of of poverty in informal settlements, integrated those currently practicing open defecation and response are necessary that address the multiple improving water supply for residents promote and interacting causes of COVID-19 vulnerability. hygienic practices that limit transmission. These To this end, coordinated responses that utilise the interventions should be coupled with public technical expertise of various humanitarian and health messaging, which provide residents with development agencies are required. Afghanistan’s clear guidance on limiting transmission in the humanitarian Inter Cluster Coordination Team context of overcrowding and low-capacity WASH, (ICCT) provides a key programmatic modality to and that is tailored to the needs of women. address multi-dimensional vulnerability, linking Durable solution: In the medium to longer emergency response actions by organisations term, upgrading housing, WASH and local across health, WASH, nutrition, shelter, food infrastructure will strengthen the resilience of security and protection. Increased coordination the community to COVID-19 and other shocks. between humanitarian and development actors These investments can be facilitated through could see emergency responses transition into community-based organisations, using a cash- longer-term resilience outcomes, including for-work modality that draws on labour from the livelihood support and settlement upgrading. settlement. This will improve living conditions, Gender inequality is a key issue in COVID-19 support local livelihoods and contribute to up- response. Female-headed households report skilling the local workforce, reducing COVID-19 the lowest incomes, suffer the worst food transmission risk and strengthening community insecurity and most often practice open resilience to the disease. defecation. In response, gender inclusion should

COVID-19 vulnerability in informal settlements: 7 a case study of an urban IDP community in Jalalabad, Afghanistan be mainstreamed across all aspects of COVID-19 will protect the most vulnerable residents in related interventions, from the provision of public Afghan society, and also reduce broader urban health advice, to gender-inclusive participatory and societal transmission rates by preventing site planning and training programmes for COVID-19 cluster outbreaks in high density livelihood support. urban informal settlements that can easily spread beyond the community. In this regard, the 4. Toolkit for assessing informal settlement following toolkit can be used to rapidly identify vulnerability to COVID-19 informal settlement vulnerability and actions to Data-led responses can focus limited resources reduce transmission and increase socioeconomic to prevent COVID-19 transmission on the resilience: most at-risk urban informal settlements. The effective deployment of resources in this manner

Gender- disaggregated Emergency response Durable solution vulnerability indicators

- Number of people per - Provision of PPE and - Settlement upgrading dwelling sanitary kits

Risk of - Access to improved - Clean water transmission WASH facilities - Public health messaging - Access to clean water

- Household income - Unconditional cash - Sustainable livelihoods transfers - Livelihood activities Socioeconomic - Days with insufficient resilience food

- Dietary information

8 COVID-19 vulnerability in informal settlements: a case study of an urban IDP community in Jalalabad, Afghanistan References

Bonato, Giulia, Lorenzo Dioscoridi, and Massimiliano Mutignani. 2020. “Faecal-Oral Transmission of SARS-COV-2: Practical Implications.” Gastroenterology. IOM. 2020. Displacement Tracking Matrix for Afghanistan. Available at https://dtm.iom.int/ afghanistan. Mol, Marcos Paulo Gomes, and Sérgio Caldas. 2020. “Can the Human Coronavirus Epidemic Also Spread through Solid Waste?” Waste Management & Research: 0734242X20918312. Mousavi, Sayed H. et al. 2020. “The First COVID-19 Case in Afghanistan Acquired from Iran.” The Lancet Infectious Diseases. OCHA. 2020. Afghanistan Brief: COVID-19 No. 39 (26 April 2020). Available at https://www. humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/daily_brief_ covid-19_26_april_2020.pdf. Poole, Danielle N. et al. 2020. “Responding to the COVID-19 Pandemic in Complex Humanitarian Crises.” International Journal for Equity in Health 19(1): 1–2. Shah, Jaffer et al. 2020. “COVID-19: The Current Situation in Afghanistan.” The Lancet Global Health. UN-Habitat. 2020. Key Messages: COVID and Informal Settlements. Available at https://unhabitat.org/ sites/default/files/2020/03/english_final_un-habitat_key_messages-covid19-informal_settlements.pdf. Wang et al. 2020. “Household transmission on SARS-CoV-2.” Journal of Infection. Zhou, Fei et al. 2020. “Clinical Course and Risk Factors for Mortality of Adult Inpatients with COVID-19 in Wuhan, China: A Retrospective Cohort Study.” The Lancet.

1 Author contact: Ben Flower, HLP Advisor, UN-Habitat, [email protected] ; Dr Joanna Dobbin, Academic Clinical Fellow, University College London Hospital, [email protected] 2 COVID-19 refers to the disease that results from infection of the SARS-COV-2 virus. 3 According World Bank data, the average per capita GDP in Afghanistan is around USD 583 per year (one of the lowest globally), equat- ing to around 50 USD per person per month.

COVID-19 vulnerability in informal settlements: 9 a case study of an urban IDP community in Jalalabad, Afghanistan COVID-19 VULNERABILITY IN INFORMAL SETTLEMENTS: A CASE STUDY OF AN URBAN IDP COMMUNITY IN JALALABAD, AFGHANISTAN