The poor health of those living in informal settlements across Freetown is a direct consequence of their living conditions, but often in locally specific ways. This is further exacerbated by unequal access to healthcare, meaning such communities face a double burden on their health due to the environmental conditions in which they live.
 
These are some of the findings of a research study, led by SLURC in collaboration with Future Health Systems, seeking to explore relationships between living conditions in informal settlements and common health problems, and to explore whether the socioeconomic backgrounds of people living in informal settlements affect their access to health care services.

Validation workshop
On 22 November 2018, a group of 30 community stakeholders, health professionals and policy makers came together at the Sierra Leone Urban Research Centre office in Freetown to validate the initial findings. This was an opportunity for participants from the four communities involved to discuss and validate the research findings, include any additional information that may not have been covered so far, and provide a platform for dialogue between community stakeholders and local and national government representatives around the issues raised and the ways in which these might be addressed going forwards. Following initial presentations by SLURC’s Dr Joseph Macarthy, Abu Conteh and Sudie A. Sellu, consolidating findings from focus groups and interviews, participants broke into groups to discuss and record their feedback and further ideas, before sharing these with the whole group. This was the first time all stakeholders had come together in such a way.
 
We have also held a similar validation exercise within the four communities of research, to get further views on what has come out the research so far. These included members of the wider community who had not yet participated in the research.

Many health issues in informal settlements are place-specific
It was clear from the initial research findings that there are many crosscutting issues affecting health across all the informal settlements included in the study, such as toilets, water, housing and energy use. Yet, within each of these issues, place is instrumental in driving the specific health conditions affecting each community. In Portee-Rokupa, residents travel huge distances to obtain water; in Cockle Bay, water is relatively available, yet some of the sources are contaminated by saltwater.
 
In discussion, the groups added other specific examples of the specificity of health conditions in their communities. In the hillside settlements of Dwarzark and Moyiba, accidental falls are a concern due to the terrain. Blindness is more of a concern in the seaside settlements (though causes are differentiated by gender roles - among women it is attributable to excessive smoke exposure through drying fish, while fishermen are exposed to salt water while fishing. A gender perspective has been crucial to the project – the research has found that men are more likely to use informal healthcare than women, for example. Participants shared other issues affecting all communities alike, such as strokes - believed to be prevalent due to physical strains, stress and irregular medical check-ups – and fistula - due to forced or obstructed labour caused by some inexperienced Traditional Birth Attendants.
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​People face multiple barriers to healthcare when they get ill or injured
When it comes to seeking treatment for ill health, findings from the focus groups established a range of barriers that those in Freetown’s informal settlements face when accessing healthcare, which the research team grouped into five main categories: long distances, difficult terrains, poor roads, long wait times, and the main factor - high costs. These were all corroborated by participants, and explain many of the decisions people make in how they access healthcare.

There was much discussion of social barriers, for example the role of religious and cultural beliefs, coupled with gender imbalances in health facilities in preventing some from accessing formal care. Healthworkers breaching confidentiality is another significant barrier – for example, to young women seeking family planning services. 

Nurses’ attitudes were perceived by many to be negative, putting people off seeking their care – though it was acknowledged that this might sometimes be due to high workload, lack of formal enrolment and thus low motivation.
 
Overcoming these barriers requires greater accountability

The range of participants present together in the room provided the opportunity to productively establish concrete steps towards addressing some of these barriers. Health worker recruitment should consider gender balance, ensuring that women and men are not reluctant to visit health facilities. All healthworkers should receive ethics training, ensuring patient confidentiality for people seeking care – and this could perhaps be accompanied by strict penalties for those who breach confidentiality. Greater recruitment of trained health workers would reduce the workload and thus boost motivation among those already working. Finally, inclusion of religious leaders in health sensitization activities is suggested as a positive step. In short, along with addressing the environmental factors, priority must be given to boosting accountability across all healthcare services accessed by “Freetonians” to make it more accessible and responsive to their needs.

The full report is due for publication in December.

(Quotes are all translated from Krio)

In the early hours of Wednesday, 25 April 2018, the residents of Kola Tree in Cockle Bay were awakened to the shouts of fire. The blaze took place in the informal settlement located in the Western coast of Freetown and affected 97 people. Although there were no casualties reported, rampant loss of property, possessions and livelihoods were claimed by the incident.
 
When the team from Development Planning Unit (DPU) at University College London (UCL) and Sierra Leone Urban Research Centre (SLURC) arrived at the site, they were met with chaos. A crowd of residents were still dealing with the aftermath of the fire over the rubbles of their corrugated metal sheet homes. Despite all effort to mitigate damages, the flames had been eventually extinguished by burying them under the collapsing building structures.

 
It was soon established that the Cockle Bay community was left on its own to undertake responsive actions. There were minimal external interventions save for the fire brigade who attempted to extinguish the fire alongside the residents. The DPU/SLURC team quickly came to the support of the residents by conducting an enumeration process to determine who was affected and what was the impact of the fire. This information was subsequently handed to the local leader of the Federation of the Urban and Rural Poor (FEDURP) and of the Community Based Disaster Risk Management Committee to facilitate the provision of relief for victims and temporary shelter for the night. While the source of the fire was yet to be determined, the rapid assessment conducted by partners on the ground speculated the possibility of an electrical fault. The Office of National Security (ONS) responded hours after the event and is reportedly conducting a more detailed assessment to identify the origin of the fire.

DPU team supporting the enumeration of those affected by fire in Cockle Bay. Photo by A. Allen.

The absence of external support during small-scale disasters is not unusual for informal settlements. In most circumstances, external actors such as governmental institutions and non-governmental organisations have to conserve their limited resources. Consequently, they can only respond to severe incidents. For example, a prominent local NGO was only able to support 144 of the 2,048 victims during the 2015 fire in Susan’s Bay due to the lack of funding. Minor disasters such as that in Cockle Bay accordingly tend to be overlooked and underreported. Moreover, dismal planning characterised by limited road access and dispersed and insufficient water sources also hinder evacuation and relief efforts and exacerbate the everyday risks facing local communities. Moreover, although preliminary relief is given to the victims of disasters, this is often insufficient to ensure that those affected can recover from such events, let alone to escape risk accumulation and poverty cycles.
 
It is estimated that about 547 fires outbreaks affected those living in informal settlements in Freetown between 2011 to 2015 (Di Marino et al, 2018). Fires are only one of the multiple hazards facing poor and impoverished women and men in the city on a regular basis. Other hazards include floods, mudslides, landslides, waterborne diseases, and occupational hazards, amongst others. Each of these disasters, small and large-scale, disproportionately impact the urban poor – destroying their housing, disrupting their education and in some case, even terminating their sources of livelihood.
 

The fire outbreak in Cockle Bay brings to light the broader issue of prolonged systematic oversight of informal settlements and the invisibility of certain segments of the city population, such as tenants. As the fire was confined to a mere 8 compounds within a small area of about 100m2, initial estimates speculated that about 20 people had being affected. However, the enumeration process conducted by the team in collaboration with local residents revealed that it was in fact a total of 97 people, a third of whom were children. About 80% of the victims were tenants. This yields an abrupt indication of how vulnerable groups such as tenants and the youth in households are often inadvertently not accounted for, leaving them virtually invisible by the community themselves in times of disasters.
 
Lacking the means to enter the housing and land markets elsewhere in the city, many women in men are forced to reside in informal settlements like Cockle Bay. Therefore, these areas have experienced consistent densification and land reclamation over the years, particularly since the Civil War. Aside from high housing densities, most informal settlements also face scarce provision of basic services. Communities are forced to utilise improvised infrastructures, causing overloading of electrical points. In the area affected by the blaze, all 34 families relied on two metered connections for electricity.

Everyday life in Cockle Bay. Photo by: A. Allen

Some might posit that informal settlements are hazards in themselves and ought to be eradicated. However, these settlements house a sizeable proportion of Freetown’s population, with no alternative dwelling options. Moreover, their residents perform jobs that support the daily functioning of Freetown; quietly they run the city. Demolishing their living quarters as a ‘protective measure’ against risk simply displaces the issue - disrupting lives, livelihoods, family ties and social organisations - making poor women and men even more invisible. Events like the fire in Cockle Bay remind us of the need to stop blaming the victims and victimising the poor, the need to acknowledge that they live at risk not as an exception but as a common reality, the need to seek pathways for more inclusive urbanisation beyond risk.
 
Reference
 
Di Marino, Marco; Lacroix, Lea; Nastoulas, Illias; Simpson, Paul; Trintafillides, Georgina;  Williams, Cai Anwyl ; and Yang, Deyu. (2018) Urban Risk Trap: Fire Dynamics in Freetown’s Informal Settlements. Policy Brief No. 2. SLURC/DPU Action-Learning Alliance.