17 May 2020 - Strict ‘lockdown’ containment measures, often involving the banning of non-essential movement outside the home and closure of non-essential businesses, are widely considered to be the most effective tool for limiting mobility and slowing the spread of COVID-19. But they are hugely damaging and not sustainable, especially in lower-income cities, and for low-income and high-risk populations. While the costs of lockdown are high, the benefits could also be limited where healthcare systems already struggle to cope. At the same time, cities not enacting strict measures to limit transmission in order to avoid damaging livelihoods are risking outbreaks.
The COVID-19 curve is rising in many global south cities, and city authorities are facing increasing pressure from citizens to find a sustainable path for containing the virus. This means finding intermediate containment options that can allow people to earn a living, particularly workers in the informal economy and others on daily wages while slowing the spread of COVID-19.
This article looks at what a sustainable approach to limiting community transmission could look like in global south cities through the ‘marathon’ of the COVID-19 pandemic response period. It draws on measures already being implemented in cities and learning from past health crises such as Ebola. With an emphasis on informal settlement communities and daily-wage workers, it looks at containment measures that could be applied to groups with different levels of risk and approaches to securing the behaviour change needed for these measures to be effective.
The question of how to live with the virus is relevant to all cities – whether the initial emergency response approach has used ‘lockdown’ physical distancing conditions or not, as well as those which haven’t yet experienced a local outbreak.
Stronger containment measures for COVID-19 cases and at-risk individuals
By limiting the mobility of confirmed and suspected COVID-19 cases and those who are most vulnerable to the virus, cities can help to contain the spread and limit its impact while looser restrictions apply for the rest of the population. This means supporting COVID-19 cases and their contacts to safely isolate for a quarantine period (usually 14 days), and finding locally-acceptable ways to shield vulnerable people for the longer-term.
- Providing safe isolation facilitates for COVID-19 cases and their close contacts. Suspected and confirmed COVID-19 cases who are able to safely and effectively isolate in their own home must be required to do so, even if they have no symptoms. Where they can’t, if possible, safe isolation facilities should be provided by the city authorities and partners. The same applies to their close contacts, identified through contact-tracing. This will help to limit transmission within the community. With the global tourism industry all but shut down, and many hotel rooms in cities currently empty, many city governments are working with the hospitality industry and other partners to seek isolation rooms for people who are unable to safely isolate at home. Other options in use as quarantine centres include sports facilities, reception centres and converted train carriages. Read Ramping up testing, tracing and treatment capacity in global south cities for more information about this.
- Using small-scale lockdowns targeted at locations within the city where there are outbreaks. By mapping outbreaks and using contact-tracing, targeted lockdowns have helped to manage outbreaks within cities. This approach has been used in Vietnam and has helped to deliver the low case numbers in the country. In Ho Chi Minh City, for example, the city-wide lockdown was imposed for only two weeks, with two-week lockdowns at district, apartment complex or single-street scale used to contain COVID-19 cases outside of the city-wide lockdown period. However, it is critical that this approach is not applied to whole neighbourhoods or informal settlements where people are not able to safely isolate in their home. Equally, good communication and engagement with any affected population will be vital for the acceptance and success of this approach.
- Shielding high-risk residents. Many countries have recommended that people who are more vulnerable to COVID-19, particularly the elderly and those with certain underlying health conditions, should aim to isolate even when the rest of the population is not in lockdown, to reduce risks to themselves and health services. Modelling of COVID-19 outbreaks in African cities, published on 24th April by the London School of Hygiene and Tropical Medicine, also suggests that the shielding of high-risk populations, when implemented alongside isolation of known cases and moderate physical distancing, has significant potential to substantially reduce COVID-19 mortality. Where at-risk individuals are unable to safely isolate at home, options for shielding vulnerable residents could include:
- Hotel facilities. Again, empty hotels could also provide a safe space to stay for vulnerable city residents, such as homeless or elderly people, to facilitate physical distancing during the crisis. For example, in Rio de Janeiro, the most vulnerable residents – particularly elderly people who live in the favelas – are being temporarily housed in the city’s empty hotels as a preventative measure, to reduce their exposure.
- Shielding within the community. This is an option proposed by the London School of Hygiene and Tropical Medicine. Neighbourhood-level housing ‘swaps’ could shielded safe zones where high-risk individuals can isolate together for an extended period, while less vulnerable individuals are able to continue with life as normal. Contact between the shielded and unshielded population should be minimal. To be effective, this must be community-led, with communities and civil-society actors supported to design and implement a model which would be appropriate locally – it must not be coercive.
- Minimising risk by avoiding gatherings. Where high-risk individuals are unwilling or unable to isolate themselves, they should be encouraged and supported to avoid hotspots for COVID-19 transmission such as public transport, gatherings and busy spaces as much as possible.
Moderate containment measures applying to the whole city population
A suite of measures to contain the spread of COVID-19 would need to include actions to support hand hygiene, as well as intermediate physical distancing measures. Intermediate physical distancing options applying to whole populations could include:
- Continuing and expanding the use of physically-distant business models and working practices, including for government services. The decentralisation of shopping, limits on the number of people allowed in a shop or venue at any time, and other measures which have been rapidly adopted by essential shops in ‘lockdown’ cities around the world could be replicated for other businesses. Read Emerging best practices on physical distancing in cities for more guidance on this. Physically distant models already employed for essential shops include the decentralisation of markets and shops, and increasing available space. During lockdown conditions, decentralized shopping and increased space for shopping are helping to reduce crowding. Authorities are supporting this by allowing all food shops and traders -including informal traders - to continue to operate, and opening additional venues. In Lagos, the city is utilising closed schools as market spaces, so that people can buy food and medicine without having to travel long distances and to avoid large crowds of people in central markets. In Ahmedabad, the city government is partnering with street vendors to provide a ‘vegetables on wheels’ service; vendors are issued a curfew pass to enable them to purchase food from wholesale markets, and the city government provides rickshaw drivers to drive the vendors and their stock through a designated route to sell produce (see photograph).Similar principles can be applied to shops and markets selling other products, and even bars, restaurants and other venues where physical distancing will be challenging to facilitate. For instance cities including Vilnius, the Lithuanian capital, and Wuhan are already turning over public spaces, including parking and street space, to bars, restaurants and street food vendors to support these traders to comply with physical distancing rules.