The collective insecurity generated by the pandemic requires a decisive public health response. This response has, however, tended to apply centralised, top-down and undemocratic decision-making, often using “war” narratives that prompt or reinforce fear, and that promote individual self-protection. 

Reactive interventions have not adequately taken local conditions and rights into account, prevented longer-term harms to health — including from gender violence — nor protected income, food security or social trust.

However, the pandemic also offers an important opportunity to demonstrate that alternative, people-centred, democratic and collective responses are possible. Indeed they are essential, not just to prevent and contain infection and mitigate the impact of the pandemic, but also to “build back” using a stronger, more compassionate and equity-driven form of public health.

In October, EQUINET published 42 case studies of community action on Covid-19 that collectively demonstrate examples of this. The case studies come from different settings, income levels and dimensions of the response. They show innovative and solidarity-based approaches to prevent and care for Covid-19, to address social needs and hold states accountable. They provide a powerful argument for public participation and collective action in health.

One of the case studies, the Cape Town Together Community Action Network, tells the story of a self-organising network that emerged in March 2020 in South Africa as a community-led response to Covid-19.

In early March, it was clear from other countries that formal responses would struggle to keep up with the pace of the virus. As a network of autonomous, neighbourhood-level groups working together to respond to local challenges as and when they emerge, Cape Town Together felt that bottom-up community organising could spread faster than the virus and could rapidly identify and respond to its emerging health, social and economic impacts.

The Community Action Networks (CANs) actively work against a tendency to centralise planning, decision-making and management. They reject hierarchies of knowledge, resources and power. CAN operates independently and autonomously within each neighbourhood while drawing on the collective energy and wisdom of the network as a whole. The hyper-local nature of the CANs allows for street-level organising, reminiscent of anti-apartheid activism. Generosity, trust and solidarity are important foundational principles. The CANs prioritise relationships over bureaucracy. They are enabled by interpersonal connections built during lockdown conditions largely through online co-learning, WhatsApp groups and Zoom meetings.

At the peak of the pandemic this decentralised, self-governing structure provided vital support where formal social safety nets failed, including public health guidance, mask-making clubs, community gardens, community care centres for Covid-positive people who could not safely self-isolate at home and food and medicine deliveries to elderly people.

A few weeks after South Africa initiated its hard lockdown, 47% of households were suffering from extreme food insecurity. Across Cape Town, CANs distributed food parcels and established community kitchens. With rapid communication across the network, CANs shared experience and resources, learned from each other and worked with public health services to follow Covid-19 safety protocols in the community kitchens. Beyond the hot meals provided, the community kitchens became safe, organic spaces, enabling protective behaviours and information sharing. They responded to local social needs in a way that was inclusive, welcoming and free of stigma and shame.

The CANs generated community-level intelligence. In their inclusion of community members, researchers and local public servants, they enabled informal communication. They built trust between communities and health system actors through dialogue and co-learning forums between CANs and health sector decision-makers. They made input into educational materials developed by the health department. With the lived local realities of those most affected by the pandemic often being very different from those of health department officials, these connections proved invaluable in framing appropriate measures.

The CANs aim to support and not substitute state efforts, which was initially possible. However, the shortcomings within state efforts became a subject of an increasingly politicised debate. For example, some CANs and local civil society organisations formed a coalition that protested the unlawful eviction of residents in informal settlements. Political actors reacted by asserting that the CANs were acting unlawfully and presented a political threat. When another CAN renovated a badly vandalised and unused public community hall, the local ward councillor accused them of unlawfully occupying the space.

Such tensions may be inevitable where community initiatives highlight deficits in state responses and provide different approaches. Bottom-up initiatives such as the CANs call for and contribute to alternative forms of governance that celebrate, enable and invest in community-led public health responses.

The case studies in the EQUINET report show that community-engaged and community-led responses and relationships are more likely when they build on prior histories of social networking and organisation around social justice. The relationships, the citizen scientist and activist leadership, the connections with public, professional and civil society organisations and prior activities on different dimensions of wellbeing enabled a relatively rapid, collectively organised range of health responses to the pandemic. Information technology was used to organise collective understanding and action.

The case studies also show the importance of investing in comprehensive primary healthcare systems for an effective and equitable response to pandemics. If we continue to frame our health systems only in terms of efficiency-led measures to treat particular diseases and top-down responses to emergencies, we weaken the ability to mobilise the relationships, capacities and creativity within communities, networks and service personnel, or the multi-sectoral responses needed to prevent and address the many health challenges we face from such crises.

We hear many negative stories about Covid-19. Yet these compassionate stories of equity, rights-driven and holistic responses also need to be documented and told. They show a solidarity-driven response to Covid-19, and that people are subjects not objects in health. DM/MC.

EQUINET, the Regional Network on Equity in Health in East and Southern Africa, is a network of professionals, civil society members, policymakers, state officials and others within the region who have come together as an equity catalyst, to promote and realise shared values of equity and social justice in health. 

Eleanor Whyle is a PhD candidate studying the socio-political evolution of NHI policy in South Africa at the Health Policy and Systems Division, University of Cape Town. Manya van Ryneveld is a health systems researcher with training in social anthropology at the School of Public Health, University of the Western Cape. Leanne Brady is a public sector doctor turned health systems researcher at Emergency Medical Services, Western Cape Department of Health. She is also a PhD candidate at the Health Policy and Systems Division, UCT, focusing on health systems resilience, and the health system’s responses to societal violence. Dr Rene Loewenson is an epidemiologist and leads the Training and Research Support Centre at EQUINET.

This article first appeared in EQUINET newsletter