As Uganda Strives To Be Open Defecation Free, Anti-Toilet Beliefs and Habits Persist

KOTIDO, UGANDA — For Lokomolo Apakuna, the problem is not so much having a latrine. It’s keeping it.

Apakuna, 60, lives in the Kotido district, in Uganda’s Karamoja region. His homestead had a latrine made of mud and wood, but extreme rains in recent years destroyed it.

“It went down two years ago. The logs were eaten by termites. When the rain came, the wall went down. We now use the bushes. Our plan is to construct a latrine during the dry season,” Apakuna says.

As he speaks, a family member returns from the bush after responding to nature’s call. It’s a scene repeated often for the 12 people who live on the homestead: Apakuna and his wife, their seven children and three grandchildren. The smell and mess along the paths to his land and grazing area make Apakuna appreciate proper sanitation.

“Latrines are good if they are there. Now there are feces everywhere. You don’t find that when we have a latrine,” he says.

Apakuna’s story highlights the challenge of promoting proper sanitation and hygiene in the Karamoja region, where officials estimate that the majority of people do not have regular access to toilet facilities.

The Ministry of Health and NGOs have tried to promote toilet usage in Karamoja through community education programs – and by publicly naming and shaming leaders with no toilets at home. But the region still has the lowest sanitation indicators, in part due to beliefs that devalue toilet usage.

For example, in Karamoja, a traditional belief holds that a person should not share a latrine with an in-law. It is also believed that if a pregnant woman uses a latrine, she may lose her unborn baby.

The Karamoja region has a high prevalence of diarrhea and typhoid, diseases often linked to poor sanitation and hygiene. During rainy season, wells, boreholes and streams get contaminated by runoff from places where feces have been deposited. A study conducted by the World Bank’s Water and Sanitation Program estimates the health care costs related to poor sanitation at 389 billion Ugandan shillings ($105 million USD) nationwide every year.

In many ways, Karamoja’s sanitation challenges run parallel with those of the rest of Uganda.
According to the Ministry of Health website, Uganda’s latrine coverage increased from 49% in 1997 to 79% in 2018. Only 10% of the population was living in open defecation-free communities at the end of 2018. The 2014 National Housing and Population Census indicated that about 8% of Uganda’s households have no toilets, with rural areas like Karamoja having the poorest indicators.

Jonathan Longoli, project coordinator for WASH Caritas Kotido Diocese, is optimistic that the people of Karamoja, referred to as the Karimojong, will adopt latrines someday – but only with the right interventions.

In 2018, Caritas investigated why adopting good sanitation practices in Karamoja was such a nightmare, Longoli says.

“We did research on barriers to improved sanitation and hygiene – and type of terrain where termites eat structures, drought that causes families to migrate, most of the time were cited,” he says.

Longoli says Caritas Uganda has been working with local leaders to sensitize communities in the region to the dangers of poor sanitation, including illnesses like diarrhea and typhoid, which can be a consequence of poor hygiene. Caritas also fixed water facilities, such as sinks in schools mounted on concrete, to facilitate hand washing, Longoli says.

Joseph Orisa, information officer for Kotido district’s local government, says district officials have hosted open defecation-free village events for the past three years. These events showcase local technology for making latrines, like using logs to cover latrine pits and grass from grazing land as roof cover. Officials present local leaders with posters declaring their villages open defecation-free and a bull to roast and celebrate amid dancing, he says.

But some villagers revert to old practices soon after the celebration ends.

“For some people, after the open defecation-free declaration, they go back to open defecation. Others claim termites have eaten latrines. Behavior change is a cultural issue. Pregnant mothers fear using latrines that a child can drop in. It’s cultural. If they are also endowed with a lot of land, someone can easily enter bush and do pupu,” Orisa says.

Kotido business owner Kyemuta Berna says most landlords don’t have toilets on their premises.

Kyemuta owns a supermarket and says that the very few toilets available in the central Kotido business area. As a result, many people use them, and they fill up fast.

“Public toilets in town are few. Some even come and close theirs, so we have very few we use,” she says.
Despite the challenges, the Kotido district government continues to educate the public via mass media about the dangers of open defecation.

“Once a week we have a radio program on Voice of Karamoja in Kotido,” Orisa says. “We talk about it every Friday from 4 to 5 p.m. The district health officer talks on it, and the nutrition focal persons, water and sanitation committee members, the chief administrative officer and the political wing, including the LC 5 chairperson and resident district commissioners and head of departments talk there.”

The radio program educates listeners on hygiene practices to avoid sanitation-related illnesses.

“They teach them on dangers of open defecation, like typhoid, dysentery, etc. Government spends a lot of money on treatment and most of these diseases related to poor sanitation. Diarrhea is a big burden to children. They teach them how to make a usable latrine, how to dispose of pupu of children. They are taught on hand washing with soap. Some who can’t afford soap are told to use ash and wash hands after going to the latrine,” Orisa says.

One of the other approaches has been to name and shame public leaders who have no latrine in their homes.

“We published a shame list of local leaders and civil servants who are not living by example,” Orisa says. “We did verifications in these homes. The names were read on a radio, Voice of Karamoja, and also put on notice boards at the district offices. After that they all constructed toilets in their homes.”

The name-and-shame campaign was highly contentious, but politicians’ objections haven’t derailed the strategy. “In the last meeting we had, we resolved in that meeting that the list should again published. There is a new shame list. It has not been published yet,” Orisa says.

Enock Kusasira, public relations officer for Uganda’s Ministry of Health, says the government has a sanitation fund which has been used for public education over the past two years in three Karamoja districts, including Napak and Nakapiripirit.

He says since they started their operations, Nakapiripirit district has reached 70% toilet coverage. They hope that by the end of 2020, Napak toilet coverage will have increased equally.

Communities are encouraged to construct low-cost latrines with local materials and offered information to improve hygiene and sanitation.

“For example, we ask how many places have you defecated today, and they count. Then we ask how many kilos are those? We ask them where their water sources are and whether the feces won’t eventually end up there,” Kusasira says. “There is certainly a difference in toilet coverage in areas in which Ministry of Health is implementing behavior-change interventions, as compared to those areas where they are not operating currently.”

In Kotido district, toilet coverage has increased from 5% in 2010 to 26%, Orisa says.

But Kusasira acknowledges that there is still a lot to be done.

“Behavior change is a process. It is not an event. It is gradual, adopting new practices, taking up new desired practices. There is a need to invest more resources, especially where the Ministry of Health is not operating, because they still have the lowest sanitation indicators in the country,” he says.

Ochwero Marcello, GPJ, translated some interviews from Ngakarimajong.