Shock tactics: urban health futures in the wake of Ebola

Lead Research Organisation: Institute of Development Studies
Department Name: Research Department

Abstract

This research will address the interconnected challenges of rising urbanisation and vulnerability to infectious disease. From acute epidemics to slower onset issues such as antibiotic resistance, the world is facing a resurgence of infectious disease challenges. Far from being a thing of the past, these diseases have the potential to spread extensively in densely populated urban settings and to 'go global'. A major implication emerging from crises like Ebola (2014-15) and Zika (2015-16) is that dramatic inequities and pockets of severe neglect in public health standards leave us all vulnerable. Though their burdens fall most acutely on the poor, they also increase the potential for unmanageable crises with broader demographic impacts. Of particular concern are rapidly growing urban settlements which have played a role in exacerbating recent epidemics and where sanitary conditions pose an increasingly intractable challenge to health and development in many cities across the world.

The majority of the world's population already live in urban environments and numbers are predicted to rise dramatically. A large and growing proportion of these urban residents live in informal slum-like settlements. We know very little about how health systems are organised in these rapidly changing contexts, except that they are highly informal and old rules and approaches do not apply. The Ebola epidemic in particular revealed glaring gaps in evidence and understanding of these environments and populations, with fatal consequences. Indeed, it revealed there were pervasive misunderstandings and misrepresentations in policy circles which make interventions for both epidemic control and for basic public health difficult. Yet Ebola has also created a window of opportunity, both to understand the health challenges in informal settlements better and as the impetus to do things differently.

This research will focus on health in informal settlements in Freetown, Sierra Leone, in the aftermath of Ebola. It will explore if and how such a major epidemic is changing the game and what lessons can be drawn for other contexts. To be able to know this we need a much deeper understanding of the social, political and economic relationships which surround urban health systems and which will determine the opportunities for change. Although aspects of the political and social determinants of urban health have been broadly characterized, less is known about the logics and practices of health in informal settlements from the perspectives and experiences of local community members - for example urban residents' own understandings of transmission, or socially embedded hygiene practices. It is equally unclear how such local norms and practices do or do not connect to policy understandings of these contexts, and to what effect. As such, the objectives of this research project are:

1. To elucidate the social and political processes and practices of health systems and disease control in informal urban settlements, as represented and experienced by different actors, using ethnographic and participatory methods to understand and incorporate residents' own perspectives and practices;
2. To identify institutional arrangements emerging in Sierra Leone post-Ebola which have the potential for improving or worsening health in informal urban settlements;
3. To contribute to health systems strengthening and to epidemic preparedness and control in urban areas by integrating perspectives from medical anthropology, urban studies, and public health.

The project will be a collaboration between a UK anthropologist with over 7 years' experience in Sierra Leone and a new urban research centre based in Freetown. The combination of in-country experience and local partnerships provides a unique platform to develop cutting edge perspectives on urban health, informed by a deep understanding of the city and of global health politics and practice.

Planned Impact

This research aims to improve the health of people living in informal urban settlements. The residents of these settlements face particularly high disease burdens and are vulnerable to infectious disease epidemics. They are also frequently stigmatised, ignored or misunderstood by policy makers and other members of society. The Ebola epidemic brought many of these issues to the fore and has created an opportunity to learn from and about them and bring about positive changes, which this research will actively contribute to. Beneficiaries of this research are
a) the residents of informal urban settlements in Freetown, Sierra Leone, and indirectly those further afield too
b) policy makers and people working in sectors relevant to urban health in Sierra Leone
c) researchers working on urbanisation, public health and health systems and
d) the wider global health community working on issues of strengthening health systems.

For the residents themselves, the research will produce practical insights into institutional arrangements that can improve their health and health systems in their settlements. It will address incorrect assumptions about their behaviours and practices and highlight what actions they are already taking which could be supported.

The project's participatory methods will provide a platform to co-produce improvements in urban health between the residents of Freetown's informal settlements and policy makers and practitioners, including civil society organisations, local NGOs, and city officials (e.g. in the Mayor's office) and other government policy makers (e.g. in the Ministry of Health and Sanitation). The use of foresight with these groups will foster integrated multi-stakeholder and multi-sectoral planning for urban health. Each group will be able to clarify their priorities and perspectives, which, in addition to the activities in the Impact Plan (see Pathways to Impact), will result in enhanced understandings and integration of diverse perspectives on infection control. This will enable more nuanced and locally sensitive policies to address health related shocks and challenges, and increased trust.

Both researchers and members of the wider global health community will benefit from new inter-disciplinary networks and collaborations across the fields of medical anthropology, urban studies, and public health. For researchers working on urbanisation and health systems the research will synthesise perspectives in medical anthropology and urban studies which will offer new theoretical and empirical understandings of the relationships between power, knowledge, informality and visibility in urban health. This new synthesis, which will be rooted in ethnographic understandings of social and political histories, processes and practices, will deepen systems and resilience thinking. It will contribute practically to approaches to health systems strengthening policies and to ensuring that positive lessons are learned and supported from the Ebola epidemic.
 
Description GCRF Accountability for Informal Urban Equity Hub
Amount £12,156,514 (GBP)
Funding ID ES/S00811X/1 
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 02/2019 
End 05/2024
 
Description SoNAR-Global - A Global Social Sciences Network for Infectious Threats and Antimicrobial Resistance 
Organisation Amsterdam Institute for Global Health and Development (AIGHD)
Country Netherlands 
Sector Private 
PI Contribution We are a core partner in the SoNAR-Global network. We will contribute to network building, and the mobilisation of social science expertise to address infectious threats (including contextual knowledge arising from the current ESRC award) and supporting rapid response surge capacity.
Collaborator Contribution Institut Pasteur lead the grant. Network partners are responsible for work packages including: networking, resilience frameworks, models for engagement, and capacity strengthening
Impact This project has only just commenced and is in the inception period. The network which is being built is multi-disciplinary across the social sciences (anthropology, history, law, ethics, international relations etc) and with links to epidemic response agencies and the biological sciences.
Start Year 2019
 
Description SoNAR-Global - A Global Social Sciences Network for Infectious Threats and Antimicrobial Resistance 
Organisation BRAC University
Country Bangladesh 
Sector Academic/University 
PI Contribution We are a core partner in the SoNAR-Global network. We will contribute to network building, and the mobilisation of social science expertise to address infectious threats (including contextual knowledge arising from the current ESRC award) and supporting rapid response surge capacity.
Collaborator Contribution Institut Pasteur lead the grant. Network partners are responsible for work packages including: networking, resilience frameworks, models for engagement, and capacity strengthening
Impact This project has only just commenced and is in the inception period. The network which is being built is multi-disciplinary across the social sciences (anthropology, history, law, ethics, international relations etc) and with links to epidemic response agencies and the biological sciences.
Start Year 2019
 
Description SoNAR-Global - A Global Social Sciences Network for Infectious Threats and Antimicrobial Resistance 
Organisation Mahidol University
Country Thailand 
Sector Academic/University 
PI Contribution We are a core partner in the SoNAR-Global network. We will contribute to network building, and the mobilisation of social science expertise to address infectious threats (including contextual knowledge arising from the current ESRC award) and supporting rapid response surge capacity.
Collaborator Contribution Institut Pasteur lead the grant. Network partners are responsible for work packages including: networking, resilience frameworks, models for engagement, and capacity strengthening
Impact This project has only just commenced and is in the inception period. The network which is being built is multi-disciplinary across the social sciences (anthropology, history, law, ethics, international relations etc) and with links to epidemic response agencies and the biological sciences.
Start Year 2019
 
Description SoNAR-Global - A Global Social Sciences Network for Infectious Threats and Antimicrobial Resistance 
Organisation Makerere University
Country Uganda 
Sector Academic/University 
PI Contribution We are a core partner in the SoNAR-Global network. We will contribute to network building, and the mobilisation of social science expertise to address infectious threats (including contextual knowledge arising from the current ESRC award) and supporting rapid response surge capacity.
Collaborator Contribution Institut Pasteur lead the grant. Network partners are responsible for work packages including: networking, resilience frameworks, models for engagement, and capacity strengthening
Impact This project has only just commenced and is in the inception period. The network which is being built is multi-disciplinary across the social sciences (anthropology, history, law, ethics, international relations etc) and with links to epidemic response agencies and the biological sciences.
Start Year 2019
 
Description SoNAR-Global - A Global Social Sciences Network for Infectious Threats and Antimicrobial Resistance 
Organisation Medical University of Vienna
Country Austria 
Sector Academic/University 
PI Contribution We are a core partner in the SoNAR-Global network. We will contribute to network building, and the mobilisation of social science expertise to address infectious threats (including contextual knowledge arising from the current ESRC award) and supporting rapid response surge capacity.
Collaborator Contribution Institut Pasteur lead the grant. Network partners are responsible for work packages including: networking, resilience frameworks, models for engagement, and capacity strengthening
Impact This project has only just commenced and is in the inception period. The network which is being built is multi-disciplinary across the social sciences (anthropology, history, law, ethics, international relations etc) and with links to epidemic response agencies and the biological sciences.
Start Year 2019
 
Description SoNAR-Global - A Global Social Sciences Network for Infectious Threats and Antimicrobial Resistance 
Organisation Pasteur Institute, Paris
Country France 
Sector Academic/University 
PI Contribution We are a core partner in the SoNAR-Global network. We will contribute to network building, and the mobilisation of social science expertise to address infectious threats (including contextual knowledge arising from the current ESRC award) and supporting rapid response surge capacity.
Collaborator Contribution Institut Pasteur lead the grant. Network partners are responsible for work packages including: networking, resilience frameworks, models for engagement, and capacity strengthening
Impact This project has only just commenced and is in the inception period. The network which is being built is multi-disciplinary across the social sciences (anthropology, history, law, ethics, international relations etc) and with links to epidemic response agencies and the biological sciences.
Start Year 2019
 
Description SoNAR-Global - A Global Social Sciences Network for Infectious Threats and Antimicrobial Resistance 
Organisation University College London
Country United Kingdom 
Sector Academic/University 
PI Contribution We are a core partner in the SoNAR-Global network. We will contribute to network building, and the mobilisation of social science expertise to address infectious threats (including contextual knowledge arising from the current ESRC award) and supporting rapid response surge capacity.
Collaborator Contribution Institut Pasteur lead the grant. Network partners are responsible for work packages including: networking, resilience frameworks, models for engagement, and capacity strengthening
Impact This project has only just commenced and is in the inception period. The network which is being built is multi-disciplinary across the social sciences (anthropology, history, law, ethics, international relations etc) and with links to epidemic response agencies and the biological sciences.
Start Year 2019
 
Description Participatory Impact Pathways Analysis (PIPA) workshops in two informal settlements in Freetown 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact Two, 2-day workshops of participatory action research were carried out in two informal settlements in Freetown. Each workshop involved 16 participants (8 men, 8 women), including local residents, authority figures, and civil society groups (total participants = 32 people). The aim of the workshop was to identify local priorities and strategies to address infectious threats in each community. Day 1 explored concepts and meanings of contagion and infectious disease, and the functioning of existing efforts to control disease. It concluded with the identification of community goals and priorities. Day 2 focused on how to achieve those priorities. Participants developed 'impact pathways' which identified activities, outputs, outcomes and impacts of their plans, and the relationships required to achieve their goals. Participants came away with a clear and feasible proposal to address health priorities. Researchers gained a deeper understanding of local politics and forms of collective action which can be supported with the research.
Year(s) Of Engagement Activity 2019
 
Description Urbanization and the learning agenda for health systems research 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact A blog outlining the learning agenda for health systems researchers on urbanization. It was an initial attempt to bring two academic communities together (urban studies, and health systems and policy researchers). The blog fed into the proposal development process for a large consortium bid which is under consideration (through to the second round).
Year(s) Of Engagement Activity 2018
URL http://www.futurehealthsystems.org/blog/2018/9/21/urbanization-and-the-learning-agenda-for-health-sy...