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Story Publication logo August 29, 2014

Unclogging Uganda's Rural Sanitation Crisis


Image by Sam Loewenberg. Uganda, 2014.

Uganda has a sanitation crisis, and it will take innovative solutions to help this country suffering...

Media file: p1040725.jpg
In the village of Bwondha, as in much of Uganda, the same body of water is used for drinking, watering animals, washing and defecation. Image by Sam Loewenberg. Uganda, 2014.

WALUMBE, Uganda — On the beach in this fishing village nestled on the shores of Lake Victoria, a rickety sign reads, "Bathing, defecating or urinating in the water: fine 20,000 [Ugandan shillings]" — about $7.80, a week's wages. The sign does not seem to be much of a deterrent, however. Just a few meters away, dozens of people go about their daily business in the lake — children splash, women fill up plastic canisters, a man washes a motorcycle. Water is at the center of life here.

But water is also a source of disease. A stone's throw from where the village's residents wash and gather water, bobbing green reeds line the shore. This semiprivate area serves as a toilet for many of the villagers. The result is that waterborne diseases, including diarrhea, scabies, trachoma and schistosomiasis, abound. In fact, in the local language, the name "Walumbe" means death, as the area was once plagued by tsetse flies carrying sleeping sickness.

The health and sanitation problems facing Walumbe are common across much of Uganda, a largely rural country. Poor sanitation and hygiene are contributing factors to three-quarters of the diseases found here, according to Julian Kyomuhangi, assistant commissioner for environmental health at Uganda's Ministry of Health.

Only about 34 percent of the population has access to hygienically constructed toilets, according to the World Health Organization. (The Ugandan government, which uses broader criteria than the WHO, asserts that the figure is more than twice that. Western foreign-aid officials familiar with the issue suggest this is a highly inflated number). According to the World Bank's Water and Sanitation Program (WSP), poor sanitation costs the country an estimated $177 million per year (equivalent to about 1.1 percent of GDP) because of premature deaths due to diarrhea, malnutrition and diseases like malaria and measles. Each year, diarrhea alone takes the lives of 19,700 Ugandan children under 5 years old. It's a vicious cycle: Poor communities cannot afford good sanitation, so people get sick, and fall deeper into poverty.

While some sub-Saharan African countries, such as Rwanda, have made important strides in sanitation, Uganda's progress has been clogged by various obstacles — an impoverished and poorly educated population, shaky governance and high-level government corruption — that are common in many nations in the region. In Uganda's case, though, they are especially pronounced. While the country is a large recipient of international aid and was once considered a model of good governance, in recent years the government of President Yoweri Museveni has been mired in mismanagement and corruption scandals.

"Sanitation has been marginalized," said Betty Bigombe, the former state minister for water, who now works at the World Bank. She says the issue is an "orphan," with the ministries of water, education and health all failing to take responsibility.

Parasitic worms

One of the most devious of Walumbe's common diseases is schistosomiasis. When people suffering from the disease go to the bathroom outdoors, close to Lake Victoria, tiny worms in their feces and urine called blood flukes find a host in water-dwelling snails. The snails release larval forms of the worms that burrow into unbroken skin, where they take up residence in the blood vessels and reproduce until their offspring are again excreted, and the process repeats.

"It's all about poor sanitation," said Dr. Edridah Muheki, who oversees neglected tropical diseases for the Uganda Ministry of Health.

Schistosomiasis is second only to malaria among devastating parasitic diseases, affecting more than 200 million people around the world, according to the U.S. Centers for Disease Control and Prevention. In Uganda alone, an estimated 4 million are affected.

Since November, villagers in Walumbe have been receiving anti-worming medication in an attempt to control the disease's spread. The medication is provided by the Schistosomiasis Control Initiative, a project based out of Imperial College, London, that works with the Ugandan government and receives financial support from U.S. and British government aid agencies.

The frustrating reality in Walumbe and so many other communities is that people would not be infected with schistosomiasis and many other diseases in the first place if they had decent sanitation. This is true for many common diseases. In the case of diarrhea, one of the world's top killers of children, a 2010 study in the International Journal of Epidemiology found that proper sanitation reduced the risk by 36 percent. Hand washing had an even bigger impact, 48 percent.

But just 29 percent of Uganda's population wash their hands with soap after visiting the toilet, according to the Ministry of Health's Kyomuhangi. She says that's in part because the government has done little to educate people about the importance of hand washing.

Overall, the government spends just $2 million a year on sanitation across this country of nearly 36 million people, an amount that Bigombe calls "negligible."

This lack of attention to sanitation isn't unique to Uganda. Despite evidence that spending money on sanitation reduces health costs and improves workforce productivity over the long term, foreign donors and most governments in developing nations have not made it a spending priority. Of the eight U.N. millennium development goals, improving sanitation is among the biggest failures. Globally, an estimated 2.5 billion people lack access to "improved sanitation" — in other words, toilets that properly dispose of waste. There are no exact figures for what percentage of the more than $450 million the United States gives to Uganda annually is directed toward sanitation, but based on global averages, it's probably only several hundred thousand dollars.

Still, it is hard to say that Uganda's problems are due primarily to a lack of resources. A 2013 report by Human Rights Watch cited "the misappropriation of state resources budgeted for public services," saying that money meant for health and basic infrastructure was diverted because of the country's entrenched system of political patronage. A report by the WSP and the Water Integrity Network, a European NGO, found "grand corruption" in the water and sanitation sector. "Services and investments have been targeted towards affluent communities at the expense of poor people," the report said, and while anti-corruption measures exist on paper, they haven't translated into action.

A 2010 cable sent to former Secretary of State Hillary Clinton from Jerry P. Lanier, then U.S. ambassador to Uganda, bore the subject line, "Uganda's All-You-Can-Eat Corruption Buffet." In the cable, which was revealed by Wikileaks, Lanier wrote, "Senior officials from the Ministries of Foreign Affairs, Security, Health, Education, Local Government, Trade, Public Works, Finance, Agriculture, Interior Affairs, Tourism, the Office of the Vice President, and the Office of the Prime Minister are currently embroiled in a dizzying array of on-going corruption scandals." He cited a report by the Ministry of Water and Environment estimating that corruption in the water sector cost the country more than $25 million between 2002 and 2009.

Yet even with the information about the country's widespread corruption, the United States did not slow down the flow of aid, at least not until recently. In June, it reduced aid dollars to the East African country over an anti-gay law.

Community solutions

So if the central government can't be relied on, what's the solution? Foreign aid officials working on sanitation in Uganda say the most effective model they've found is one that shifts the burden to local communities. Developed in Bangladesh in 1999, the method, known as Community Led Total Sanitation, or CLTS, is a low-cost, low-tech approach that has been embraced by the U.S. Agency for International Development, the World Bank and other aid agencies because it is cheap, relatively quick and demonstrates powerful results — at least in the short term.

The program, loosely administered by local health officials, is being rolled out slowly and hasn't yet reached Walumbe. But in Kibuku district, in the eastern part of the country, which has a population of 183,844, it appears to have spurred dramatic gains. Sanitation coverage in the district has gone from 47 percent to 84 percent since the CLTS program began in 2011, according to Paul Mulomi, secretary for health education for the district.

The CLTS approach incites so-called behavior change by triggering a "sense of disgust or shame." Martin Pooda, a CLTS facilitator in Kapiyani village describes the process: First, the "shit tour," in which villagers show health workers the spots where they defecate. This is also known as the "walk of shame." Next, the health workers scoop some poop off the ground and mix it in a bottle with water and then offer it to the villagers. This is the disgust part of the process. "Then they realize they are eating or drinking their shit," said Pooda. The community then passes a bylaw at the health workers' encouragement: Within three weeks, everyone must dig a latrine.

But in Kapiyani, the village government went further: "They told us if you don't build a toilet, we shall take you to police and to court," said one young resident who declined to give his name. The tactic is not an official part of CLTS; the village chief admitted it was his idea, designed to hammer the message home.

This kind of coercion is one of the pitfalls of the community-led, shame-based model. As international development researcher Liz Chaterjee wrote in The Guardian, an emphasis on coercion can undermine the success of projects, as people will sometimes use toilets out of fear without understanding the health benefits.

Even supporters of CLTS acknowledge that without sustained monitoring and education, many people will eventually stop using toilets. And if toilets are not built properly and maintained, they can actually make the situation worse.

Another tool the government has been using is the Bible, said Wilson Namungha, a government health inspector and local sanitation coordinator. Specifically, Ugandan health-ministry officials cite Deuteronomy 23:12-15, which encourages sanitation practices, and warns that if a community is unclean, God will reject it.

But without accountable public officials or properly implemented public investments, ordinary Ugandans are going to be left to deal with sanitation problems on their own. As Ambassador Lanier noted, "Uganda's image as a model for good governance is essentially a thing of the past."


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