Inequality in the (Post-) Pandemic City: Public Health and Urban Preparedness

Originally published by the Global Research Programme on Inequality

“The impact of COVID-19 and the recommended measures revealed underlying inequity in the society, most prominently in urban areas. Hopefully, the experience from this pandemic will result in prioritization of public health as well as addressing inequality in urban areas,”

– writes Hinta Meijerink from the Norwegian Institute of Public Health in this interview with GRIP.

The Global Research Programme on Inequality’s (GRIP) series “Inequality in the (Post-) Pandemic City” probes how different dimensions of inequality are shaped, exacerbated, materialized or co-exist in globally diverse urban contexts. In this series, we provide insights from researchers, scholars and specialists, asking how the effects of the pandemic, including the virus itself or the intervention measures associated with it, are impacting people and communities, particularly in relation to economic, political, social, cultural, environmental and knowledge-based inequalities. 

For this week’s contribution, GRIP has talked with Senior Advisor Hinta Meijerink at the Norwegian Institute of Public Health (NIPH). NIPH recently published the report “Urbanization and preparedness for outbreaks with high-impact respiratory pathogens”, approaching the challenges related tourban preparedness for outbreaks of respiratory diseases. 

In NIPH’s recent report inequity is highlighted as one of the main urban risk factors for outbreaks. Could you elaborate on what kind of dimensions of inequity the report refers to and in what ways they might affect disease outbreaks? 

The report identifies various dimensions of inequity that could affect outbreaks. A main aspect is economic and social inequity, those with less economic means cannot afford implementing the recommended infection control measures, especially in countries without or with weak social safety nets. For example, many people rely on informal economies and earn their living daily and cannot afford to stay home with mild symptoms as they will lose their income. This is evident by the increase in hunger, unemployment and evictions during the COVID-19 epidemic worldwide (many papers have been published on these issues, such as this one). Often individuals with the lowest economic status are those most impacted by the control measures, as well as those with increased risk due to underlying conditions and those living in more crowded spaces. In addition, individuals with lower economic status may not have the ability to afford health services, and some cannot afford certain preventive measures like face masks. 

Often communication is also challenging, as there is a lack of information to non-majority groups due to for example language, illiteracy, and cultural sensitivity. The standard communication often does not reach these marginalized populations and therefore there is a need for targeted information to non-majority groups, often involving community peers. 

When inequality and marginalized groups are not considered during outbreaks, this can lead to non-compliance of the measure resulting in increased spread and increased inequality, such as increased unemployment, evictions, and hunger. Therefore, it is crucial to consider supportive measures and targeted communications. 

What are the experiences and lessons learned regarding urban preparedness from the COVID-19 pandemic? What new insights on urban preparedness were gained from this pandemic in general, and in the case of Oslo more specifically? 

In general, we have seen that densely populated areas are harder hit, e.g. New York, as expected. However, the COVID-19 pandemic shows that quick response and strict measures can turn the outbreak. Many measures recommended during the COVID-19 pandemic were unimaginable and considered non-effective prior to this pandemic, such as large-scale quarantine of contacts. This illustrates the importance of adjusting measures recommended to the pathogen and the importance to identify and recommend control measures based on evidence.  

Having an updated pandemic plan for Oslo was of high value during the outbreak. Certain elements, such as contact tracing, were not included and demonstrates that pandemic preparedness plans should be updated and evaluated both during and between outbreaks to include the relevant elements. The population in Oslo, like many urban areas, is very diverse and therefore it is essential to communicate and involve all populations to ensure large understanding and uptake of control measures. In addition, it is crucial to focus on targeted measures based on where we see the highest number of cases, like within households, and in private settings like family celebrations, private parties and religious events. Cross-sectorial involvement in both the preparedness planning and during the pandemic itself is a key to secure the implementation and compliance to the infection control measures. 

Non-pharmaceutical interventions (personal protective measures, travel restrictions, lockdowns) have been one of the main response mechanisms employed by the authorities during the COVID-19 pandemic. The usage of such interventions has been unprecedent. What insights, both positive and negative, can we draw from these experiences, in relation to city preparedness, pandemic planning and inequalities? 

The COVID-19 pandemic has shown us the importance of rapid identification and isolation of infected individuals, as well as that tracing contacts is essential to slow the spread of the infection, especially in urban settings. Various studies have shown that the combination of testing, self-isolation, contact tracing and quarantine is effective in slowing the spread of COVID-19 (ref example). In addition, social distancing and hygienic measures have shown to be useful tools. The scientific evidence for some measures, such as face masks, is limited, making it difficult to decide on what to advise. Many people experience COVID measure fatigue, resulting in less uptake of the measures, therefore it is important to balance the measures. Effective measures against the pandemic can have negative side effects that disproportionally affects those with low socio-economic status, such as unemployment and lack of income, social isolation, and reduced access to education. 

The report comes with a long list of recommendations for urban preparedness for outbreaks of respiratory diseases. What is new in these recommendations that we have not seen before and why?  

In general, recommendations regarding preparedness for outbreaks are often given at a national level and therefore we aimed to provide recommendations specifically for urban regions. National preparedness plans are crucial, but urban areas often have their own dynamics that are not covered by the national plans as well as being affected more severely and rapidly than other areas. Specific recommendations for urban areas were therefore needed. In addition, it is important to have local adaptations depending on the local situation, not only for urban setting, but also for rural settings. National plans and recommendations may need to be increased of toned a bit for certain areas, for example several Norwegian municipalities have not reported a single case up till now and recommended non-pharmaceutical interventions (NPI) in cities will not be relevant for those regions.  

Essential for proper pandemic preparedness planning is the integration into sustainable, pre-existing structures and cross interdisciplinary needs. Urban areas often need to prioritize due to limited funding and measures that affect multiple disciplines are more likely to be sustainable, for example developing biking lanes and providing subsidies for bikes will decrease the risk of disease spread as well as decrease pollution. Integration of preparedness plans will differ from place to place, but urban areas collaborate and exchange experiences to identify what works.  

A robust public health system that allows identification of outbreaks, timely response and rapid adaptation to outbreaks, while including all facets of the health care system, is essential in the response to outbreaks as well as for the prioritization of funds and supplies. Especially the ability to rapidly increase capacity, both in health systems and laboratories, has shown to be essential for the COVID-19 response.  

How might this pandemic change the urban preparedness planning in the future, and how could that affect the urban orders?  

The COVID-19 pandemic has shown the importance of pandemic preparedness and coordination of actions, especially in urban areas, as well as the importance of a robust public health system. Flexibility was crucial in the response to COVID-19, including, but not limited to, scaling up of activities such as testing, ability to redirect resources (both monetary and human), adjusting advice based on new evidence and collaboration between sectors. In addition, the impact of COVID-19 and the recommended measures revealed underlying inequity in the society, most prominently in urban areas. Hopefully, the experience from this pandemic will result in prioritization of public health as well as addressing inequality in urban areas. 

The Global Research Programme on Inequality (GRIP) is a radically interdisciplinary research programme that views inequality as both a fundamental challenge to human well-being and as an impediment to achieving the ambitions of the 2030 Agenda.