A biomedical approach to tackling Covid-19 has led to an unjust burden on the poor. To redress the balance, we must first dismantle the power imbalances and political obstacles that act as barriers to basic rights, health and well-being for all
On 25 March 2020, the Bangladesh government declared a rigid national lockdown to respond to the Covid-19 pandemic, like the strategy adopted worldwide by many countries. The army and police were deployed to force citizens to comply. The entire country came to a standstill. With the lockdown extended every few weeks for two months, people were in limbo, confused and petrified, scared of Covid-19, but mostly worried about starvation. The young women I was working with lived in slum settlements in Dhaka city, where most residents rely on an informal economy and daily wages to survive. Here are some of the conversations I had, which reflected the panic:
There is no food in the house, we are down to our last sack of rice and our savings are dwindling … what will we do? Yes, we heard of Corona, but we fear because we have no income … what will we eat? (Female, 22 years old.)
The police caught my friend and I … we were selling fruit. I had tried pulling a rickshaw in April because we needed an income, but the police caught me and I was fined and abused. (Male, 26 years old.)
Everyone is talking about a virus, but my children are hungry. How will we manage? Do you know when the lockdown will end? (Female adolescent.)
Dhaka city has a population of approximately 16 million, with an estimated 3,394 slums with about 7 million residents. It is an economic hub that has grown chaotically, with unplanned urbanisation, bursting to absorb the 20 million residents, with the largest number of slum settlements. During the first lockdown from March to May 2020, no one could leave their homes, whether one lived in a well-to-do suburb or a slum. The Covid-19 narrative focused on the clinical approach, with biomedical strategies dominating, with little regard to differing contexts and intersectional factors, which disproportionately affect vulnerable populations. Feelings of safety and security settled into many neighbourhoods. But for the poor, with no work available and the country completely shut down, most already living precarious lives, it meant food deprivation and a sudden loss of wages, among many other challenges.
A dire situation
In Bangladesh, the clinical message focused on maintaining distance, wearing masks, washing hands frequently and remaining confined at home. Anyone who has visited a slum or shanty town, be it in Dhaka city, Nairobi or in other countries, will immediately observe crowded environments, often with five or more families squeezed into small, dilapidated, flimsy housing, with erratic water supply, unhygienic latrines and waste. These second-class citizens live in squalor, face insecure tenure, and can barely afford soap and masks. With income loss added because of the lockdowns, the situation was dire. Many residents are at the bottom of the social hierarchy, with little power and voice, yet they are responsible for keeping the city functioning and ensuring that the privileged live in comfort – by disposing of their waste, cleaning their houses and offices, supplying local transport and working in factories, retail and hospitality industries. These jobs are poorly paid and can be labour intensive.
Practising social distancing, washing hands with soap and staying home are next to impossible for the vulnerable people living in slums. The complex factors that underlie and affect the lives and health of marginalised populations need to be recognised. Research has found evidence of adverse impacts of the lockdowns on the urban poor who basically were left without any income source and who could not follow the mandated guidelines because of their living conditions. Studies in rural and urban areas found high levels of mental distress, reduced food intake, and mounting loans and huge debts. One survey of 4,872 households, with 54% from urban slums, 45% from rural areas and 1% from the Chittagong Hill Tracts region, found that households in slums experienced a more drastic ‘income shock’ due to both Covid-19 lockdowns. All this caused an ongoing negative domino effect, which continues well into 2022. Women have been even more unfairly burdened, having to do household chores and care for children, with a majority responsible for taking loans and ensuring repayment, often with interest to money lenders. This has resulted in heightened anxiety and stress. For many of the urban slum poorest, everyday life is already a battle and the pandemic was one addition to a long list of challenges for survival. The lockdown exacerbated their insecurities, as they already had erratic and meagre earnings and now had no work. Somehow these people still manage to demonstrate impressive resilience, but they are continually confronted with illnesses and deaths and living on the edge.
Reaching a socially just model
Bangladesh, like many other countries, rolled out an economic stimulus package to address the severe economic and business fallout from the pandemic. Numerous reports detail the mismanagement of relief, with weak governance a huge obstacle. The political and social actions taken at the global, national, sub-national and local levels need to respond to the context of the urban poor residing in slums in low- and middle-income countries, as Covid-19 has led to worsening poverty and the wider social, economic and political determinants of health are stacked heavily against these people. A strong political commitment, globally and nationally, with a responsive research agenda is the first step to developing and delivering policies and strategies that are supported by data. This agenda must be developed in partnership with affected communities, civil society organisations, practitioners and a team of multidisciplinary researchers, particularly social scientists, which should inform current and future policies.
We need to ensure a socially just model in public health, as an individual’s health and well-being are directly interconnected with their cash flow, housing and local environment. In any crisis, the state’s immediate response must have a long-term comprehensive approach with immediate cash and food relief, and subsidies in health care, for the most vulnerable, for longer periods. Structural and social inequalities and inequities persist in Bangladesh, particularly in urban slums – and in many other countries. The accountability of global actors is also key. With Covid-19 there was vaccine hoarding by some developed countries and rising border restrictions, with many migrant labourers forcibly sent back to their home countries. Unfair trade policies continue, which unfavourably affect low- and middle-income countries. Unless we also address some of these macro power imbalances and political obstacles, and an absence of global solidarity, we will be unable to ensure the basic rights, health and well-being of all human beings.