case study | 1 July, 2018 | By Tom Norton , Arup - Human Factors

Understanding the problemA field trip to refugee settlements in Uganda

As the crow flies, the shores of Lake Albert, on the border between the Democratic Republic of Congo and Uganda, are a shade under 4,000 miles from London. On one side of the lake lies the Democratic Republic of Congo, an unstable country in central Africa that is not in the habit of making the news for positive reasons. Currently, tribal warfare, potentially fuelled by foreign business interests, is driving hundreds of thousands of people away from their homes.

Many are traveling across the lake to Uganda, which has shrugged off its own troubled past to emerge as a safe-haven for Rwandans, Congolese, and South Sudanese. In late June 2018, it also accepted a team of people from Arup and British Red Cross visiting the Kyangwali refugee settlement area in western Uganda as part of a project to improve handwashing behaviour in humanitarian crisis events.

The project aligns to the United Nations’ Sustainable Development Goal for water, and aspires to reduce the prevalence of communicable diseases such as pneumonia, diarrhoea, and cholera that account for roughly a third of child deaths annually.

The latter is as common as the flu in the Congo, and an outbreak in Kyangwali in February killed dozens of people before being contained. Uganda Red Cross attribute the almost routine nature of cholera to sanitation and hygiene practices, or rather lack thereof, in traditional regional cultures. In combination with the contaminated water, which is all too common in rural areas such as those welcoming refugees, this creates a dangerous, though not insurmountable, problem.

Part of the answer lies in the handwashing facilities one finds at the landing sites, the reception centres where refugees are processed and registered, and the settlement areas where they can build a new life. Technologically, taps break, tanks run dry, soap is dropped on the ground, and jerry cans are stolen. Behaviourally, educational material misses the mark, while practice and rehearsal is undermined by the facilities themselves. This is the challenge taken up by Arup, British Red Cross, the London School of Hygiene and Tropical Medicine, and Butyl products.

Material contamination makes handwashing both vital and challenging

And so it was that five members of the project team travelled to Uganda to visit Kyangwali and experience the problem first-hand. With the tremendous support of the wider team and Uganda Red Cross, the team spent five days speaking with volunteers and senior figures from a variety of organisations involved in the refugee mission, visiting refugee areas to observe the handwashing facilities and behaviour, and, crucially, talking with the refugees themselves to understand their experience.

Stephen Philips checking children’s understanding of tick and cross symbols

Sebagoro is a small fishing village, with roughly as many long-horned Ankole cattle as people. Flat-bottomed fishing boats sit alongside those that carry refugees across from the Congo. For many, Sebagoro is the first paragraph in the Ugandan chapter of their life, for others it’s one they are already familiar with. The day we visited it was relatively quiet.

A single boat arrived that day, and the refugees were moving from a covered concrete area onto a brightly coloured bus for the drive to the Kagoma reception centre in Kyangwali. Some of the arrivals would be staying a little longer. These are known as ‘recyclers’, refugees who, after being given land and materials at the reception centre, return to the Congo and repeat the cycle. The surplus land and materials are sold or leased for an additional source of income. This seems to be more of an annoyance than a problem, at this stage. The logic of keeping suspected recyclers overnight is that the genuine refugees stay, while those who already have a footing in Uganda will leave in the night.

Ankole cattle horns puncture the horizon on the shores of Lake Albert; beyond lies the war-torn Democratic Republic of Congo

The communal pit latrine a few hundred metres from the shade of the concrete area was in the process of being decommissioned. The flood of refugees has slowed to a trickle of late, and a toilet block much closer to the shade, previously reserved for volunteers, is now deemed sufficient. The first handwashing facility some Congolese would see wouldn’t look out of place in London; a porcelain sink with a mirror above it and a depression to hold a bar of soap. To complement this was a far more typical unit for this part of the world; a large blue keg with a tap at the bottom and (heavily) chlorinated water inside.

Two such units were available to refugees before they boarded the bus. Nearby were several 10,000 litre tanks used for drinking water. These drew water from the lake, which was filtered and, until recently, flowed from a 6-tap frame. As this was being explained to us, a young woman carried a jerry can down to the shore to fill it. As she returned home, a cow wandered into the water twenty metres away and defecated. Beside me, a little boy stood quietly among us. At some point, the garment he was wearing had been a shirt, but all that remained now was a collar, some patches of sleeves, and tattered material covering his back. The facilities at the landing site appeared sufficient for the number of refugees there that day. Ominously, one of the belligerents in the Congo was threatening an escalation in violence in early July. Despite this, nothing was being done to prepare for a day when scores of boats carrying hundreds of people appears on the horizon.

Refugees wait to board the bus taking them from Kagoma to a settlement area

The bus ride from Sebagoro to the Kagoma reception centre in Kyangwali is bumpy, if not picturesque. Baboons, warthogs, and antelope dot the green landscape. Soon, the jungle envelopes the bus, and the ground degrades into a dirt track that is impassable after a good rain. When refugees file of the bus at Kagoma, the very first thing they do is wash their hands at stations manned by volunteers who ensure everyone complies.

Mandatory handwashing at the gates to Kagoma reception centre

From here, they receive a medical examination and are given hot food. Next comes food and material with which to build a new home, and it’s back on another bus to be driven to one of the settlement areas. The atmosphere is, now at least, very calm. This is perhaps unexpected, although the UNHCR manager of the camp, a Syrian/Palestinian named Abdul, explained that the stressful part of their flight is over. “They’re safe, they have food, we are looking after them”. Abdul values the calm environment of the camp, and is no stranger to cholera. His third and most recent bout saw him evacuated to Kampala where the doctor revealed the hospital was not equipped to treat cholera. The doctor, perhaps hopefully, thought Abdul wanted someone to help him with his smoker’s cough.

The Ugandan government provides each refugee family a 50m x 50m plot of land, which is enough for a small house, a latrine, and space to grow food. The refugees have temporary accommodation while they build their house, and each settlement area has a model home to use as a guide. These model homes are mud-brick construction with a tin roof (also covered in mud and reeds to weigh it down and keep it cool, a well-ventilated cooking area, separate quarters for animals, and a pit latrine several metres from the house. The latrines feature a pit dug to between 1.5 and 2m, although this is sometimes difficult in rocky soil, covered by wooden logs and a plastic cover.

woman decants water outside a typical house in rural Uganda

Outside the latrine is a “tippy-tap”, a simple handwashing unit featuring a frame of two upright legs connected by a horizontal arm. Suspended from the horizontal is a vessel, which is connected to a foot pedal. Operating the foot pedal tips the vessel so that water pours out. Often, an old water bottle will have been cut open to make a simple tray to store soap.

The tippy tap is ubiquitous in humanitarian crises areas across the globe. It’s simple construction, utilising basic materials sourced locally make it easy to build and maintain. It is limited, however, by the strength of those materials and the capacity of the vessel. Refilling is necessarily frequent, and requires either disassembling the entire construction, or pouring water from a larger vessel into the smaller one, leading to wastage. Keeping the tippy-tap topped up is, in large part, a motivational problem.

The ubiquitous tippy-tap

Educating people with varying degrees of familiarity with basic sanitation starts early. We visited two schools, each of which featured “washing hands” on the weekly curriculum. According to the volunteers, it’s easier to teach the children than the adults, who carry the burden of a longer lifetime of habit. Some of the educational material, however, could be improved. For example, one diagram used by several of the agencies active in Kyangwali shows some of the key pathways through which faecal matter can be ingested.

The thought of ingesting human waste is universally disgusting, however the key consequence is not pictured. Disgusting though this may be, the real danger is how this can easily lead to fatal outcomes.

Another challenge is the variety of handwashing facilities used. Tippy taps are different from the sinks refugees meet at Sebagoro, which are different still from the bucket-and-taps used at Kagoma. The differences may seem esoteric, but they might represent a barrier to behaviour change nevertheless.

A school handwashing station. Toilets are called latrines in Uganda, and many of the children at the school are below reading age.
The queue of jerry cans at Mombasa

At the Mombasa settlement area, we noticed a long queue of yellow jerry cans, baking in the equatorial sun near an empty 10,000L tank, empty for two days. The vessels are fundamental to life in developing countries. The truck arrived while we were there, and the cans were duly filled and taking back for cooking, cleaning, and, hopefully, handwashing. The water is pulled from a nearby river where it undergoes a sophisticated process of filtration and treatment before distribution. This occurs near the river, at the bottom of a steep slope serviced by a muddy road.

The gradient is unsuitable for the trucks, and so the treated water is pumped a few hundred metres up the hill to where the gradient is more truck-friendly, and stored in a combination of tanks and bladders. Without the pump, the challenge of transporting the water from the treatment facility would be infinitely more difficult. Tens of thousands of people depend on this small pump, for which there is no backup. Uganda receives a similar amount of rain as the UK and the river supplying Kyangwali roars. The system that connects that rain, that river, to the people that need it is, however, scarily fragile.

Kennedy explaining the water treatment process. Also pictured is the pump on which 85,000 people depend

At base camp we sat with many of the volunteers who greatly assisted our trip, translating our strange questions and the answers they prompt. Though the volunteers empathise strongly with the refugees (many are refugees themselves), there are concerns they are not as effective as they could be.

A volunteer with a t-shirt demonstrating effective handwashing

Volunteers make a distinction between handwashing (wet) and effective handwashing (wet, lather, rinse). When asked how many houses they visited that day, the volunteers proudly responded “Thirty”. But when asked what the Uganda Red Cross’ seven principles were, all you could hear was the din of weaver birds constructing their nests in a nearby tree.

Rather than practicing effective sanitation education, spending time to make sure the message is understood and embedded, the volunteers show a desire to meet their (counterproductive) quota of house visits. Little wonder, then, that refugee families often relapse into poor sanitation and hygiene, and that volunteers have little faith that a household will be still practice effective handwashing in the absence of regular reminders.

A young girl demonstrates how she washes her hands, paying particular attention to her nails

Driving back for the return flight from Entebbe, infamous for a 1976 hostage crisis, the group visited Hoima, the district’s municipal capital. On the way, we pass people walking with supplies resting on their heads, motorcycles with chickens dangling precariously off the back, trucks filled with people, and an odd pair of goats resting in the middle of a lane.

An ideal handwashing solution would use local industry to try and close the loop and create a more sustainable outcome.

While the hardware stores in Hoima can supply large plumbing equipment, such as tanks and pipes, and each community appears to have a metal fabricator, other items such as sinks and, perhaps unsurprisingly then, taps, are rare. While the options for transporting materials is many and varied, the overall supply of materials to construct robust and functional handwashing units leaves much to be desired.

Motorcycles are a lifeline in Uganda, transporting everything from fish to families, and mattresses to water tanks

Our goal is to design and prototype a handwashing unit, and our field trip highlighted the broader system that determines how successful our unit, or any unit for that matter, might hope to be. Around the unit sits a broader technical environment, comprising the underlying infrastructure and the availability of parts. These need to be reliable so that the unit can do what it needs to.

There is also a human environment, including social, cultural, and motivational elements. Learning materials need to tell the whole story and delivered effectively in a manner appropriate for the audience.

People need to understand why handwashing is important, and connect the dots between practising effective handwashing and not falling ill.

Smiles are not a rare resource in Uganda

In the middle of Kampala is the central mosque. A beautiful building, as elaborate mosques tend to be, it is a gift from one Muammar Gaddafi. Consequently, Gaddafi has something of a good reputation in Uganda, certainly better than his reputation in Tripoli to say the least. Uganda is no stranger to strangers who look and, too frequently, take without giving back. This is an echo of the historic and asymmetric ebb and flow of benefits between Africa and the rest of the world. Arup’s mission is to shape a better world, and we are bound by this to ensure what Uganda gets out of us is at least equal to what we took from Uganda.