In 2019 a suspended health centre in south western Uganda was turned into an Ebola screening point. Despite not meeting basic hygiene safety standards, such as having a toilet, an international humanitarian organisation proceeded to screen potentially ill patients. Failing to address many of the region’s health priorities, the case highlights the gap between local needs and international agendas.

Clinicians at Karambi Health Centre in Kasese district, south western Uganda, are mandated to conduct outpatients’ treatment and admissions. The health centre has a maternity ward and a general ward, and although the centre can admit and treat up to 100 mothers, the latter activity was suspended due to appalling sanitation. For three years, the centre has had no toilet. In early July 2019, the centre manager consequently suspended admissions and antenatal care. Villagers were instructed to seek medical attention elsewhere. Karambi was transformed into a ghost medical facility overnight.

Villagers’ response to the suspensions was quick in seeking healthcare at far away yet functional centres, including Kagando and Bwera hospitals. A few Congolese still sought medical care at Karambi, having travelled a long distance, who were not aware of past activities in the village and did not mind much about centre sanitation.

Ebola screening without basic hygiene facilities

But from early October 2019, the International Rescue Committee (IRC) were active at Karambi Health Centre (HC111). They erected a huge bright blue umbrella, and placed strategically at the main entrance for Ebola screening purposes a hand washing facility (made from a plastic container with a 0.05% chlorine disinfectant mixture) and a bucket donated by British People. Two highly paid personnel employed by the IRC were deployed to ensure clients at Karambi HC111 adhered to Ebola surveillance activities.

The IRC staff were trained not to pay attention to the non-functional Karambi HC111. Instead they couched their activities within the framework of assisting clinicians to conduct free triage – though their main objective was to screen people for Ebola. Only one medical personnel was assigned to re-direct healthcare seekers to another medical centre, who also doubled as our respondent during frequent visits. The IRC keenly registered each guest/client and took their temperature, instructing everybody to wash hands in the chlorine mixture. It’s a triage process, argued one IRC Ebola screener.

When the two-people team employed by the IRC were asked about their experience of working under the umbrella for the entire day, they said: ‘the IRC knows it. We told them already that the hospital has no sanitary facilities and when it rains, we only put the umbrella at the HC111 gate man’s place until it stops, but this is more than one month now.’

The IRC promised to construct a semi-permanent Ebola isolation unit. The unit would have all the facilities required for disease control, such as power supply, running water, sanitary facilities and protective gear. It was planned that by December 2019 the Karambi Ebola screening point would be modified into an Ebola control and isolation facility. In short, conditions for disease control would significantly improve.

A Karambi subcounty environmental health officer was interviewed about the poor health centre hygiene, and the conversely thriving Ebola response activities. He elaborated on all the steps he had taken for the past three years to improve hygiene, ‘which were fruitless’. He presented the issue at the subcounty council meetings, the District Health Office and to various Ebola sensitisation seminars organised by humanitarian workers, ‘but the information seemed to fall on deaf ears’. On the best approach to solve this problem, he said:

‘[We should] construct an ecosan toilet, which can be regularly emptied by the health centre. It is a costly investment, but the hospital will be dealing with this issue once and for all. For example, you see the compound of this HC111, there are many toilet structures which have been used and abandoned after a short time. There are so many people from Congo who visit this health centre. Only one of the pit latrines can be emptied but it is really difficult. This is because people here, especially Congolese do not use toilet paper, they use soil, stones, tree branches. Even if one tries their best, one has to abandon the project’.

Enforcement of community hygiene practices

That a health centre lacks a toilet is a major health threat for Karambi subcounty management, clinicians and the district health office. Clinicians have previously sensitised villagers to the importance of good hygiene in their homes, but now people no longer listen to their talks. During these talks, clinicians would visit villagers to administer vaccines to children, distribute free insecticide treated mosquito nets (when procured by the Ministry of Health) and increase awareness of good hygienic practices, which include the need for a toilet in every household and boiling river water before drinking it.

In August 2019 clinicians worked together with the subcounty authorities to ensure increased coverage for toilets in the village. Having discovered a very low number, clinicians ordered the arrest of over 70 villagers who did not have pit latrines. Mostly women were arrested since the men fled. The subcounty passed a bylaw that each of the arrested people would help each other to construct a pit latrine before they are released. But realising that this act would lose him votes, President Museveni ordered that all people arrested for being ‘idle and disorderly’ be released with immediate effect, much to the subcounty chief’s dismay. Now health centre clinicians return to the spotlight. How will they promote health and hygienic practices when their health centre has no latrine?

On 10 October 2019, I attended a council meeting held at Karambi subcounty, with the subcounty chief in attendance, who said:

‘We need an emergency pit latrine at Karambi health centre 111. This is because many people, including Congolese seek well-being there. By the time the Congolese arrive there and they are told to go somewhere else, the situation might be too late, particularly for pregnant women.’

The chair suggested that about two million shillings (US$ 540) meant for constructing an abattoir would be diverted to this activity. It was debated and agreed upon that a committee of five people within the council would mobilise the local youth to dig and construct a pit latrine within two weeks. The issue will then ‘temporarily resolve in this way’.

By March 2020, Karambi HC11 still faced poor sanitation. The Kasese District Health Office was aware of Karambi’s problem, though an officer lamented complications in the procurement process and a lack of funds. The subcounty was warned about the consequences of diverting funds, as well as audit queries, which they might not want to deal with in the future.

I observe that subcounty management indeed struggled with an issue of procurement and the re-location of resources to solve a major health threat. In one management meeting it was also agreed that the status of Karambi HC111 was shameful and an emergency to resolve.

Public authorities and strategic deployment of power

A longitudinal assessment of the role of public authorities in the Karambi HC111 issue brings the following to the fore: concerned stakeholders can see, experience and discuss an issue differently. While Karambi patients may experience poor sanitation, and be inconvenienced by the appalling nature of their service provider, the clinician faces credibility issues over the extent to which healthcare seekers trust his services. Clinicians’ respect is at stake, especially when no villager is listening to their regular sensitisation sessions about the importance of living in a good hygienic environment.

Humanitarian workers’ preset frameworks

The IRC’s humanitarians in the defective Karambi health centre only saw Ebola as the threat, epitomising humanitarian interventions that use preset frameworks in crisis settings – designed from abroad but executed in local settings. Indeed humanitarians are often overwhelmed by what they find in local settings, yet they are obliged to adhere to their organisations’ financial plans.

I consider local priorities discovered by humanitarian workers unknown knowns, which must be strategically neglected in order to make their work manageable. By ignoring glaring priorities, and sometimes pretending not to see the local realities, humanitarian workers are able to proceed with the execution of their project and report success stories. If the IRC was more concerned about record keeping, hand washing and temperature taking, then the IRC’s project registered tremendous success amidst a crisis, owing to its reporting parameters.

Strategic needs by humanitarians reinforce the extent to which various authorities will engage with local priorities. Thereby I propose that villagers themselves need to devise ways to deal with their own realities and only view other interventions as complimentary to what they already have.

Photo: UNMEER/Martine Perret. Licensed under creative commons (CC BY-ND 2.0).