A random walk around Zone 3, Block 4 in Palabek Settlement camp, a swarm of flies that were feasting on faeces at different spots, flee to safety. A few metres away, children aged eight and 10 walk barefooted in the nearby bushes, gardens and rocks that make up the beautiful scenery of the camp’s shacks passing as houses for the refugees.
Opened in 2017, the camp located 60km away from Ngomoromo, a small border post in northern Uganda, accommodates more than 30,000 refugees from South Sudan who fled the raging war between government forces and those allied to rebel leader, Riek Machar.
A few pit-latrines constructed at the establishment of the camp by relief agencies dot the area, but many consider visiting them a luxury.
Keven Amony, one of the leaders in the camp, says it is not uncommon for infectious disease such as diarrhoea to strike the camp and that they are now living in fear of a cholera outbreak like the case has been in other camps with similar practices.
“It has not been easy for us to stop open defecation mainly because most people here are ignorant and primitive. What even makes it worse is that many are hostile, which makes sensitisation hard,” Amony says.
Cases of cholera outbreak and related deaths in refugee camps blamed on open defecation have been reported in several other refugee camps across the country.
In 2016, cholera broke out in Bidi Bidi Refugee Settlement camp in Yumbe District, infecting 53 people. The Ministry of Health said it was as a result of poor sanitation.
In the same year, a cholera outbreak was confirmed in Pagirinya Refugee Settlement in Dzaipi Sub-county, Adjumani District, affecting 40 people. This was also blamed on the failure to observe personal hygiene and embrace the use of pit latrines.
Another outbreak occurred in February this year, where more than 1,400 cholera cases were registered and 35 people confirmed dead in Kyangwali Refugee Settlement camp in Hoima District.
The settlement camp largely accommodates refugees from the neighbouring Democratic Republic of Congo (DRC) who also escaped war in their country.
The cases registered at two treatment centres in Kasonga and Sebagoro in Kyangwali and Kabwoya sub-counties, respectively, were largely blamed on open defecation due to the refugees’ reluctance to dig pit-latrines or use the available public toilets.
But the incident also acted as an eye opener to the leaders in Palebek Refugee Settlement camp to start an oversight role and guarantee sanitation in the area so as to avert similar incidents from occurring.
Going to bushes
Every morning, Amony watches her neighbours as they vanish into the nearby bushes and rocks to answer the call of nature rather than use either the grass thatched or iron sheets pit-latrines that were built by non-government organisations.
“And it is not just children but even the adults do the same, especially in the evening and early morning hours,” says the mother of three.
The alarming state of affairs, according to Simon Peter Okot, the block leader, forced them at the beginning of this year to create health committees to play an oversight role of sanitation in each of the zonal blocks .`
Okot says every block is composed of elected leaders representing different zones in a particular block.
“These leaders also act as health promoters to sensitise residents and ensure that every homestead constructs a pit-latrine, and rubbish pit, especially for those who are not willing,” says Okot.
Every homestead, according to the block leader, must have a pit-latrine, a rack to hang washed utensils and a rubbish pit where to dispose household garbage as the set rules dictate.
Okot says their committee in Block 4 has since passed by-laws to start fining whoever does not abide by the established rules, including confiscating their maize grain from the United Nations High Commission for Refugees (UNHCR) until they have the structures erected. UNHCR is a global body responsible for refugees.
“If you have been caught defecating in the open, you would be fined Shs10,000 and faeces for children fined Shs5,000. Whoever refuses to abide by the by-laws will be reported,” adds the block leader, who is also a member of the committee.
The committee also punishes defiant members who fail to pay the fine by confiscating the food they are given by UNHCR until they either pay the stipulated fines or commit to stop open defecation, construct pit-latrines and racks, Okot says.
According to World Health Organisation (WHO) fact sheet, poor sanitation is linked to transmission of diseases such as cholera, diarrhea, dysentery, hepatitis A, typhoid and polio.
Open defecation also perpetuates a vicious cycle of disease and poverty in which countries where the vice is most widespread have the highest number of deaths of children aged fewer than five as well as the highest levels of malnutrition and poverty.
As such, Okot says health promoters and leaders in the camp are tasked to keep watch, identify and impose penalties on the violators of the laws on open defecation.
The refugees who were settled by the Office of the Prime Minister (OPM) under whose jurisdiction the refugees fall, and UNHCR, were allocated a 30 by 30 piece of land for each household, enough to also have a pit-latrine erected.
However, Elia Solomon Futto who lives with his 25 children and three wives in the camp, attributes the poor sanitation to limited resources such as iron sheets and timber to construct pit-latrines and racks since not all refugees can afford them.
“As you see many of them are starting to have pit-latrines. The challenge they have is that they do not have logs to construct pit-latrines,” says Futto.
But Okot stresses that the refugees who are still reluctant to comply are the defiant ones since majority of the residents have endeavoured to adjust and adhere to the new rules, which has reduced the cases of diarrhoea in the camp.
Other camp leaders also attribute the practice to cultural taboos among some tribes of the refugees such as not sharing pit-latrines with their in-laws among others, making some of them to practice open defecation.
Daily Monitor could not, however, verify whether the taboos indeed existed among the named tribes in the camp since the faulted groups disputed the accusations as rumours perpetrated by their colleagues from other tribes.
WHO reports indicate that Uganda spends more than $380 million, which is approximately Shs1.4 trillion, on treating diseases that are sanitation-related and diseases that can be prevented with good hygiene practices.
WHO estimates that a total of 1.1 billion people (15 per cent of the global population) practise open defecation, 949 million open defecators live in rural areas.
Another 79 per cent of Ugandans are also said not to have pit-latrines and toilets, according to the Ministry of Health statistics.
The Office of the Prime Minister (OPM) was last year forced to relocate 4,000 South Sudanese refugees from Nyumanzi Transit Centre in Dzaipi Sub-county to the newly created Agojo Refugee Settlement in Ciforo Sub-county, Adjumani District.
These were transferred as a result of open defecation, which was a result of congestion and struggle for sanitation facilities in the former camp.
Elsewhere, open defecation also exists among the natives in other parts of the country, forcing community leaders to pass by-laws to mitigate the deadly practice.
For example, the Karimojong in north-eastern Uganda also practise open defecation because of their cultural beliefs, making the sub-region one of the poorest performers in sanitation and hygiene in the country, according to the Ministry of Health.
Another 2016 study conducted by SNV Netherlands Development Organisation, a non-governmental organistion, in the West Nile district of Arua, indicated that majority of the people preferred using bushes for defecation to pit-latrines or toilets.
Human faeces have been found to transmit many infectious diseases including cholera, typhoid, infectious hepatitis, polio, cryptosporidiosis, and ascariasis.
Open defecation, also exposes human population to dangerous bacteria, which can threaten the lives of people in the long run, the environment and healthy habitation, according to WHO.
As an intervention, the Ministry of Health in May launched a major cholera vaccination campaign targeting 360,000 people, including 70,000 refugees in an effort to contain the sporadic outbreak.
According to UNHCR, they have registered 2,276 cholera cases and 45 deaths in the different refugee camps since February this year.
According to figures from last year, Uganda is said to be the top refugee hosting nation in the world, with only Pakistan and Turkey holding more refugees.
The figure of refugees is said to be about 1.4 million.
The majority of Uganda’s refugees have fled violence in South Sudan – where civil conflict between the government and rival factions has killed tens of thousands of people since 2013.
Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae.
The short incubation period of two hours to five days is a factor that triggers the potentially explosive pattern of outbreaks, killing within hours.
Once a person is infected with cholera, develops acute watery diarrhoea with severe dehydration which leads to death if left untreated.
Cholera cases. Poor sanitation. In 2016, cholera broke out in Bidi Bidi Refugee Settlement camp in Yumbe District, infecting 53 people. The Ministry of Health said it was as a result of poor sanitation. Another outbreak occurred in February this year, where more than 1,400 cholera cases were registered and 35 people confirmed dead in Kyangwali Refugee Settlement camp in Hoima District.
This story was done in partnership with the International Women Media Foundation (IWMF), an organisation working to elevate the status of women in the media.