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Clean Water for Health in Uganda: Preventing disease in a refugee settlement

A large patient population makes it difficult to maintain a clean water supply and sustain safe hand hygiene practices at the Rwamwanja Health Center III.

Last summer, I worked with a team of Ugandan and Stanford researchers to study ways to maintain a clean water supply and sustain safe hand hygiene practices in rural health facilities in Uganda. 

Our fieldwork took us to clinics across the western region of the country. As someone passionate about human rights advocacy, I was particularly interested in Rwamwanja Health Center III, a facility located in the Rwamwanja Refugee Settlement in the Kamwenge district. 

Among countries in Africa, Uganda has the largest number of refugees -- about 1.3 million people -- due to its welcoming policies and proximity to nearby conflicts in South Sudan and the Democratic Republic of Congo. The majority of nearly 70,000 refugees living at the Rwamwanja settlement, I learned, have fled from the Congo. 

I witnessed firsthand how Rwamwanja Health Center's human and material resources were stretched to their limits. A large crowd of mothers -- many carrying infants on their backs in colorful slings known as ekyaahi -- waited patiently in front of a gray cement pavilion. They had arrived early in the morning seeking free immunizations for their children, their dedication a reflection of the dangers of communicable diseases in this context.  The outpatient department overflowed with patients, many waiting long hours beneath a UNICEF tent shading them from the intense August sun. 

Each health worker in the outpatient clinic, we were told, saw around 75 patients per day, and the maternity ward provided care for hundreds of delivering mothers every month. That large patient population makes it difficult to maintain a steady flow of clean water. Although the facility now has water piped through the national system, thanks to political activism and an influx of international donor support, the area's high population density coupled with the center's large number of patients place excessive demands on the system. Reservoir tanks are filled by pumping groundwater, and harvest tanks collect rainwater when it's available. A chlorine generator is used to dose water every morning for the health center, which has reduced the need for common substitutes such as detergent and soap. However, the tanks' piping systems and chlorination processes require regular maintenance to ensure a sustainable, uninterrupted water supply.

Maintaining safe handwashing practices also presented a challenge. Handwashing stations were scattered around the large facility, typically near each department; and at the main entrance, the askari (security guards) reminded patients entering and leaving the facility to wash their hands with chlorinated water. Every morning, staff members in the public health department hold education sessions to teach patients about the importance of hand hygiene for infection prevention. Village health teams take the message to rural communities. These practices were instituted in the wake of Ebola virus threats. Earlier in the year, suspected cases of Ebola were reported in nearby districts, and staff members worked with outside groups to prevent cases from cropping up at Rwamwanja. Remnants of the awareness campaigns, including seven-foot banners illustrating the warning signs of Ebola, were visible throughout the compound. However, while we were there the handwashing stations ran out of chlorinated water several times, emphasizing the gaps in preparedness if such an outbreak surfaced in this setting.

In our interviews, health workers and community support staff in Rwamwanja and other facilities told us that these types of efforts for Ebola prevention improved water, sanitation and hygiene, but that they worried the improvements may not be sustainable. Fear of epidemic disease, they told us, only motivates handwashing in the short term. In the long run, continued support and monitoring are needed for both health workers and patients to practice safe hygiene. Additionally, while handwashing in chlorinated water is appropriate in outbreak settings, standards from the World Health Organization recommend using a stronger cleanser on a routine basis.

These findings reinforced my commitment to our study. I hope our work will help Rwamwanja Health Center III and other similar rural health facilities move closer to sustainable interventions in the future and become better equipped to avert infectious disease outbreaks.

Harika Kottakota is a senior at Stanford majoring in molecular biology with minors in human rights and African studies.

"Clean Water for Health in Uganda" is a series providing insights from a research project, the Sustainability of WASH Services in Rural Healthcare Facilities in Uganda, which is led by Stanford's Program on Water, Health and Development. Kottakota was supported by the Stanford King Center on Global Development's Summer Undergraduate Field Research Assistant Program.

Photo of a handwashing station at a health facility in Uganda by Harika Kottakota

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