As we brace ourselves for the Covid-19 epidemic in Pakistan, we are being told to wash our hands and self-isolate. What if you are unable to do any of these things? According to the Census 2017, Pakistan's population is 207.8 million with an urban share of 75.6 million. The United Nations asserts that in 2015, 45.5% of Pakistan's urban population was living in informal settlements. Thus, an estimated 34 million people in Pakistan live in katchi abadis or urban informal settlements, where water is scarce for the most basic of needs.

In Karachi — a city of over 16 million — approximately 60% of the population lives in informal settlements with limited or no access to clean water and sanitation. Let us compare this — for a moment — with countries being devastated by Covid-19. For example, Italy and Spain, where there is almost universal access to clean water, sanitation, soap and antibacterial gels. Even with their comparatively tiny populations, the virus has spread and killed at a pace no one could imagine. So with northern health systems on the brink of collapse, will the spread of Covid-19 in Pakistan bring urban informal settlements to the frontline of the crisis?

The threat to Pakistan is palpable. As we anxiously await the impact while self-isolating, the voices of the most vulnerable are barely audible. What health threats do the 34 million people living in Pakistan’s informal settlements face? What does this mean for the spread of Covid-19 across the country? How can we leverage data for designing urgent planning interventions that will actually work?

Access to water

While the instructions for containing the spread of the virus sound fairly simple — wash your hands for 20 seconds with soap multiple times a day — it is not an easy task for the majority of Pakistan's informal settlements that are water deprived. Access to water varies massively. People living in Karachi's Machar Colony, an informal settlement at a considerable distance from the city centre, pay Rs7,000-8,000 a month in water purchased through tankers and other informal means. Residents of Gharibabad, near Karachi's PIDC, spend over Rs5,000 a month on the same. For poor households, this is a very significant portion of their earnings. The idea of using that water repeatedly for washing hands is a luxury. Here are some basic calculations on daily water use for maintaining hygiene:

Just for a single month, a household of eight would then require 750 additional gallons of water. This constitutes half of a 1,500 gallon tanker, which costs at least a minimum PKR2,500 in a typical informal settlement. The additional financial cost for basic protection against Covid-19 by washing hands, would then be around PKR1,250 per month for the family. While the figure does not seem very high in isolation, it becomes a critical portion of their income in the absence of earned daily wages amidst the current lockdown. Can a low-income family in an informal settlement even be capable of providing for this additional water expense in times when the same amount would be needed to buy essential food items?

Cost alone (leaving aside logistical factors such as water availability, transportation, waiting lines) — to perform hand washing as per government recommendations — points to the absolute urgency of making cheap water provision a top priority for informal settlements. Without that intervention, the virus is likely to spread like wildfire, the consequences of which are hard to imagine.

Such a sorry state of our existing water infrastructure is indicative of the larger problem. A 2016 International Development Research Centre (IDRC) report investigated the state of infrastructure in Pakistan's urban informal settlements. It concluded that a drastic overhaul is needed in urban planning and services to enable infrastructural upgrading, especially for public health and access to decent work. Unsanitary environments, in densely populated areas, have devastating a impact on health and livelihoods. For too long the health and social needs of such populations have been invisible. Now — our lives are more interconnected than ever — without addressing their needs, the whole city is at risk.

This brings us to the second recommended measure: social distancing. Let’s look how practical this measure is, using existing spatial and household data.

Density, space, data

The most critical input for tackling urban issues is data. What data sets do we need right now? To phrase it another way: what data-sets — open access and appropriate for secondary analyses by independent researchers or institutions to supplement the meagre data visualisation capacity of all tiers of government — actually exist, for Karachi, and for urban Pakistan?

In Sindh province, the government estimates that there are 1,414 katchi abadis out of which 575 are in Karachi and 408 in Hyderabad. A 2008 World Bank study indicates there are a total 902 katchi abadis in urban Punjab; 65 in Khyber Pakhtunkhwa, 55 in Balochistan and 52 in Islamabad. With these sparse, and potentially out of date figures, we can roughly estimate a total of 2488 informal settlements across Pakistan's major urban centres. This data excludes the numerous goths (approximately 900, as per an Orangi Pilot Project study and the Karachi Strategic Development Plan 2020, that dot Karachi's periphery; areas that are rapidly transforming into peri-urban settlements), with no clear planning regulations, no formal mechanisms for service provisions, often needing to tap into (siphoning) water and other public utilities to survive.

In cities like Karachi, there is a double deficit: data on informal settlements is either not collected regularly, and if it is, it is not disaggregated — especially on social indicators such as health. How can the various tiers of government tackle this crisis through emergency plans if they do not have realistic and up-to-date figures on the number of people living long-term in a ward or district? What about the number and type of built structures they occupy? Their proximity and interaction patterns that could facilitate the spread? The capacity and effectiveness of the infrastructures serving them? Without this data relief planning for Covid-19 becomes a guessing game at best. This provides loopholes in the relief mechanisms — loopholes that can be exploited for populistic provision rather than for where the need is highest.

The most comprehensive and reliable data on demographics in Pakistan is supposed to be gathered by the population census. Yet, reflecting on the methodology adopted for the 2017 census, this crisis demonstrates the ineffectiveness of the data: it collected de jure data on Pakistani citizens, counting them in the wards/districts displayed on their CNICs, and not where they were actually living. Such data quickly becomes irrelevant for subsequent studies, and especially unusable for detailed analysis on the realities of lives and processes in urban Pakistan. Take the Covid-19 crisis: how can governments generate epidemiological models to predict its spread in populations when there is no existing or reliable data about them?

Based on work done by the Karachi Urban Lab over 18 months and spanning 13 informal settlements in different districts of Karachi, our findings reveal that people are living on plots as small as 20 square yards. Households have an average family size of eight to nine people, but barely accommodate a single room with a slab for a kitchen and a toilet. In locations where people have expanded vertically, household sizes go as high as 30 people per 80 square yards of plot. These household numbers are higher than the average represented in the 2017 census. The reality is that social distancing is almost impossible to implement in these settings. This kind of population density rings alarm bells for the safety and security of these urban residents and for the spread of Covid-19 across Pakistan. Coupling this constriction of available space for the vast urban majority with a city-wide curfew or extended lockdown hours spells disaster for people forced to confine themselves to tiny, dense, interior spaces. In cases of smaller plots or higher densities the scenario becomes even more unnerving. This, coupled with studies which show that 88% of the housing stock in the city consists of plot sizes 120 square yards or less, lies in strong contrast to people living in houses sized 400-2000 square yards constituting only 2% of the housing stock.

Health and vulnerability

Dozens of informal settlements in Karachi have been under the threat of eviction for the past 18 months. More than one thousand households have already been rendered homeless in Karachi's District Central. Our ongoing and participatory research with residents, shows that about 40% of households in informal settlements have at least one family member who requires special medical and social care. Adding to the staggering numbers of immunocompromised individuals, there is a diversity of medical, physical and social healthcare needs. About 70% of the persons who need care can be categorised as persons with chronic illnesses who are facing a heightened risk of contracting Covid-19.

The news of Covid-19 — added to eviction anxieties — has created very high levels of psychological stress amongst residents in informal settlements. The distress of managing the food, water and healthcare needs of the family had already reached unprecedented levels but now the lockdown is leading to further disruptions and distress disorders. Psychological research repeatedly shows that stress weakens immunity.

Women and girls are particularly vulnerable to these stressors and their impact. They are most likely to be trapped at home and absorbing significantly higher levels of care work during the lockdown. Levels of violence against women and girls have spiked in the lockdowns in China, the UK and the USA — there are real concerns about the safety and security of women and girls across Pakistan, but especially those in crammed households suffering immense precariousness.

The insecurity, uncertainty, and stress puts residents of informal settlements at high risk of immune-compromisation, compounding their vulnerability to Covid-19. They are at the frontlines of this crisis.

Long-term planning

The Covid-19 pandemic should be an urgent wake-up call for urban planners, bureaucrats and policymakers in Pakistan, to invest substantially and meaningfully in understanding and levelling out the highly unequal access to urban infrastructure services. Fragmented governance and lack of accountability at multiple layers of government have hindered inclusive planning efforts for decades. Residents of informal settlements can no longer be invisible to policymakers — as they are a critical part of the functioning of the city, and as some of the most vulnerable people, they deserve due attention.

Simply put, the long-term effects of Covid-19 combined with impacts of climate change, will take place in sites and at scales that involve populations which have never been accounted for in previous planning efforts. Here is a list of both urgent and long term recommendations:

1. Restore the local government system across Pakistan.
2. Immediately establish a coordination committee of representatives from provincial/local governments, NGOs and community leaders.
3. Include and account for high numbers of persons with healthcare needs.
4. Document up-to-date numbers and generate spatial data on populations in each ward, with particular emphasis on informal settlements.
5. Prioritise emergency budgets to upgrade existing water infrastructures and include emergency provision of cheap and clean water in informal settlements.

This report has been co-authored by Adam Abdullah, Maheen Arif, Soha Macktoom, Arsam Saleem, Muhammed Toheed, Dr Nausheen H Anwar, Dr Gulnaz Anjum and Dr Amiera Sawas.

Header image: People reach out to get a charity food handout during a lockdown after Pakistan shut all markets, public places and discouraged large gatherings amid an outbreak of the coronavirus disease in Karachi, Pakistan on March 30, 2020. — Reuters