Since the emergence of the new SARS CoV-2 virus and the COVID-19 pandemic, the unprecedented pace of scientific discovery has resulted in the speedy development of new treatments and vaccines. While planning for cycles of infection surges will likely remain necessary for a while, inclusive and equitable approaches to the reporting of cases, testing, tracing, treatment and vaccination could avert disaster, particularly in many urban centres that disproportionately bear the brunt of systemic global health risks. However, this desirable outcome is yet to become a reality and the progress achieved overall has not translated into progress for all.
From the aftermath of the Arab Spring in North Africa, Ebola outbreaks and cross-border terrorism in West Africa, to rapid urban migration across coastal and inland cities and public protests in response to water, housing and energy scarcity, the disruptive and interconnected nature of recent pre-pandemic events across the continent has provoked city managers, scientists and policy-makers to develop context-sensitive and innovative alternatives to policies that have also worked in the global north. For example, back in 2015 when almost all cities signed up for the Paris Climate Agreement, city authorities worked on ambitious solar-powered LED lighting and renewable energy use in hospitals, which is cheaper to build and operate, as compared to conventional grid-based options, and has also generated a range of economic and climate benefits, including hospital operations that are not vulnerable to power shutdowns.
With the onset of the pandemic, given the diverse characteristics of cities across a historically and demographically distinct continent, the critical question in my mind is: building on these past experiences, what have we learned that we should retain and that the world could learn from, to improve urban health?
In this piece, I’ll share three reflections that could inform future efforts to improve urban health and help cities to be better prepared for future pandemics.
1. COVID-19 has shown that effective strategies to protect health will need collaboration across sectors and community engagement
Over the course of the pandemic, the different tribes of medicine (e.g. physicians, epidemiologists, virologists and others) have gained a higher level of decision-making power, informing policy responses at various levels such as National Task Forces on COVID-19. For example, the Africa Centres for Disease Control and Prevention (Africa CDC), held the first of its training sessions in early February 2020, when the 52 African countries reported more than 30,000 cases and about 1,400 deaths from the new coronavirus. By mid-March, 43 countries had gained competence to test for the virus — if appropriate reagents were accessible. This is good progress in terms of science-policy interfaces in addressing societal challenges in Africa and by Africans. But the challenges and aftereffects of COVID-19 require a broader public health systems orientation. Both medical and non-medical knowledge is required in the search for solutions, yet many of our African physicians have a solely clinical mindset that dates back to the days of confronting cholera outbreaks, typhoid, HIV/AIDS, polio and other diseases. To achieve this reorientation, experienced physicians, scientists and governments will need to incorporate the contexts of largely informal, ecologically and culturally diverse urban environments into strategies to protect, promote and improve health.
For example, in East Africa, where I’m based, an integral part of urban living is regular circular migration between cities and villages as part of strategies by both rural and urban households’ to diversify incomes and strengthen social family bonds. This reality coupled with the in-migration of refugees and internally displaced persons pose challenges for necessary pandemic-related restrictions on inter-district travels as well testing and contact tracing to reduce transmission. The urbanisation patterns of cities like Bujumbura, Mogadishu, Kinshasa, Khartoum and Juba have been partly shaped by the dynamics of civil strife and drastic political transitions. The resulting loss of trust in government has significant implications for public acceptance of restrictions on civil liberties and economic activity necessary to curb the spread of COVID-19.
2. Intersectoral collaborations for better urban health will need new types of professional training across disciplines.
The global stress of addressing critical supply shortages, including respirators, gloves, face shields, gowns, and hand sanitiser, have indicated how the recycling and re-use of urban waste can be part of the solution to unfolding global health and economic crisis. Medical health workers fashioned personal protective equipment (PPE) out of clinical waste bags, plastic aprons and borrowed skiing goggles. Achieving this reorientation to more holistic public health approaches will require a re-think of who is considered to play a crucial role in population health. Beyond the definitions of health professionals that include medical and allied health professionals, training of professionals in urban sectors like urban waste management, transport, governance and urban resilience should integrate consideration of health impact as a standard.
The COVID-19 pandemic has amplified the urgency of a transition to more cross-sector collaborations with all sectors understanding the role they can play in maintaining health. The pandemic has also highlighted why it is so important for these professionals to better listen to and engage urban residents as facilitators and agents of change to address issues of vaccine hesitancy and the adoption of non-pharmaceutical interventions. But for this to be sustained post-COVID, intersectoral collaborative mechanisms that were formed for the pandemic response will need to be institutionalised at all scales from local municipal authorities to global organisations like UNHABITAT and World Bank to ensure that African urban and health systems are better prepared for the post-COVID world.
3. COVID-19 has brought new economic opportunities that could be harnessed for urban health equity
COVID-19 has unmasked urban health inequalities globally, with respect to race, age, location, gender and other demographic characteristics. But the pandemic has also spurred the development of new economic activities, particularly in the industry and service sectors. These range from micro-scale activities such as hand-made mask vending and converting recycled plastics into face shields and masks to new larger-scale activities such as home deliveries, digital banking and virtual education economies. The exponential growth of digitisation has created jobs for youth in the context of African Agenda 2063 and the COVID-19 crisis. Mobility solutions such as Uber Taxis, Safe Boda in Kampala, and tuk-tuk rides in Cairo, Addis Ababa, Banjul and other African cities, have not only removed the breaks in neighbourhood inter-connectivity due to narrow paths and ring-roads but also highlighted the potential to break the chain of COVID-19 transmission through supporting home deliveries during stay-at-home measures, especially amongst city dwellers that are digitally literate and can afford the costs associated with the use of smart mobility strategies. However, links between the adoption of smart-mobility technologies and public health systems are underdeveloped in urban Africa. Although such linkages would bring together data on travellers’ personal details, health status and location of the nearest health unit in a way that could help control the spread of COVID-19, there have been no collaborative efforts between policymakers, public health experts and smart-mobility service providers in Africa to leverage such possibilities.
This partly explains why COVID-19 online resources and updates by ride-hailing providers such as Uber and online fast-food companies such as Jumia Food in Kampala, Uganda, on supporting drivers or delivery persons who are diagnosed with COVID-19, may have limited impact in a typical African city setting. Given that African cities are in dire need of poverty reduction, gender equality, refugee integration and youth employment, these emergent economic structures could contribute to addressing these urban challenges if they are squarely focused on addressing existing inequalities. New digital banking platforms could support pandemic recovery efforts, enabling government agencies to make cash transfers through mobile money platforms to poor households.
For example, in Kampala, National Identification Cards or passports are a legal requirement for registering SIM cards, but not all residents can comply with this. Nonetheless, electricity consumers can now pay their bills either formally (using their personal mobile phones or those registered by friends or relatives in the comfort of their homes, at work or while on travel) or informally using the outlet networks of mobile money agents that enable informal business stalls along the roadside, to function as service centres for individuals who cannot operate mobile payments on phones, due to literacy constraints or preference for walk-in service centres or lack of proper documentation to register SIM cards.
Tailoring digital innovations to address the needs of the urban poor will need data on which urban sub-populations have been left behind, and why, to inform urban policies and sector-specific programs that can potentially reach the most disadvantaged. For example, the closure of schools has challenged low-income families with no prior experience of home-schooling, whose parents are less likely to be able to work from home, and who may have less access to the internet to participate in virtual education. Similarly, the fear of deportation by refugees and undocumented workers, who already experience poorer health outcomes, meaning they are less likely to access vaccination even when available, placing them at even greater health risk.
Future efforts to (re)-build health in cities across the African continent will need to take into account these realities of urban living, leveraging the opportunities for system-wide change that the pandemic affords, if progress overall is to truly “leave no one behind”.
Kareem Buyana is an interdisciplinary researcher committed to advancing Pan-African urban scholarship for global sustainability. He has dual affiliations with Makerere University in Uganda (Department of Geography, Geo-informatics and Climatic Sciences) and the University of Florida in the USA (College of Liberal Arts and Sciences) as a researcher and adjunct assistant professor respectively.
Read more about work by Kareem and other #UrbanBetter Disruptors.