The informal settlements of the Global South are the least prepared for the pandemic of COVID-19 since basic needs such as water, toilets, sewers, drainage, waste collection, and secure and adequate housing are already in short supply or non-existent. Further, space constraints, violence, and overcrowding in slums make physical distancing and self-quarantine impractical, and the rapid spread of an infection highly likely. Residents of informal settlements are also economically vulnerable during any COVID-19 responses. Any responses to COVID-19 that do not recognize these realities will further jeopardize the survival of large segments of the urban population globally. Most top-down strategies to arrest an infectious disease will likely ignore the often-robust social groups and knowledge that already exist in many slums. Here, we offer a set of practice and policy suggestions that aim to (1) dampen the spread of COVID-19 based on the latest available science, (2) improve the likelihood of medical care for the urban poor whether or not they get infected, and (3) provide economic, social, and physical improvements and protections to the urban poor, including migrants, slum communities, and their residents, that can improve their long-term well-being. Immediate measures to protect residents of urban informal settlements, the homeless, those living in precarious settlements, and the entire population from COVID-19 include the following: (1) institute informal settlements/slum emergency planning committees in every urban informal settlement; (2) apply an immediate moratorium on evictions; (3) provide an immediate guarantee of payments to the poor; (4) immediately train and deploy community health workers; (5) immediately meet Sphere Humanitarian standards for water, sanitation, and hygiene; (6) provide immediate food assistance; (7) develop and implement a solid waste collection strategy; and (8) implement immediately a plan for mobility and health care. Lessons have been learned from earlier pandemics such as HIV and epidemics such as Ebola. They can be applied here. At the same time, the opportunity exists for public health, public administration, international aid, NGOs, and community groups to innovate beyond disaster response and move toward long-term plans.

Three hundred twelve mothers of infants aged 2-4 months in 11 slums of Indore, India, were interviewed to assess birth preparedness and complication readiness (BPACR) among them. The mothers were asked whether they followed the desired four steps while pregnant: identified a trained birth attendant, identified a health facility, arranged for transport, and saved money for emergency. Taking at least three steps was considered being well-prepared. Taking two or less steps was considered being less-prepared. One hundred forty-nine mothers (47.8%) were well-prepared. Factors associated with well-preparedness were assessed using adjusted multivariate models. Factors associated with well-preparedness were maternal literacy [odds ratio (OR)=1.9, (95%) confidence interval (CI) 1.1-3.4] and availing of antenatal services (OR=1.7, CI 1.05- 2.8). Deliveries in the slum-home were high (56.4%). Among these, skilled attendance was low (7.4%); 77.3% of them were assisted by traditional birth attendants. Skilled attendance during delivery was three times higher in well-prepared mothers compared to less-prepared mothers (OR: 3.0, CI 1.6-5.4) Antenatal outreach sessions can be used for promoting BPACR. It will be important to increase the competency of slum-based traditional birth attendants, along with promoting institutional deliveries. Key words: Birth preparedness; Complication readiness; Cross-sectional studies; Deliveries; Slums; Urban poor; India DOI: 10.3329/jhpn.v28i4.6045 J HEALTH POPUL NUTR 2010 Aug;28(4):383-391

India has the world’s second largest urban population (after China). This paper shows the large disparities within this urban population in health-related indicators. It shows the disparities for child and maternal health, provision for health care and housing conditions between the poorest quartile and the rest of the urban population for India and for several of its most populous states. In the poorest quartile of India’s urban population, only 40 per cent of 12 to 23 month-old children were completely immunized in 2004—2005, 54 per cent of under-five year-olds were stunted, 82 per cent did not have access to piped water at home and 53 per cent were not using a sanitary flush or pit toilet. The paper also shows the large disparities in eight cities between the poorest population (the population in the city that is within the poorest quartile for India’s urban areas), the population living in settlements classified as “slums” and the non-slum population. It also highlights the poor performance in some health-related indicators for the population that is not part of the poorest quartile in several states — for instance in under-five mortality rates, in the proportion of stunted children and in the proportion of households with no piped water supply to their home.

Objective To examine the association between presence of an urban health center (UHC) in proximity to a slum and immunization status of slum children in a city in India. Design Cross-sectional study. Setting Slums of Agra, India. Participants Data were obtained from a baseline survey conducted by the US Agency for International Development Environmental Health Project in 2005 in slums in Agra. The study population consisted of 1728 children aged 10 to 23 months. Information about children's immunization was obtained from interviews with mothers aged 15 to 44 years. Main Exposure Availability and proximity to a UHC that provides immunization services. Main Outcome Measures Immunization status of children, which was measured as “complete” if the child had received 1 dose of BCG vaccine, 3 doses each of diphtheria, pertussis, and tetanus and oral polio vaccines, and 1 dose of measles vaccine; “partial” if any 1 or more vaccines were missing; and “not” if no vaccine was received. Adjusted relative risk ratios compared children receiving complete or partial immunization with those not immunized. Results Adjusted models showed that presence of a UHC within 2 km of a slum was associated with more than twice the likelihood of children being completely (relative risk ratio, 2.03; 95% confidence interval, 1.12-3.66) or partially (relative risk ratio, 2.33; 95% confidence interval, 1.55-3.50) immunized. Conclusions We found that presence of a UHC was positively associated with immunization status of children in slums. These results suggest a need for greater public attention to expand coverage of slums through UHCs.