Shock tactics: urban health futures in the wake of Ebola

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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.