Mary Businge was in the doctor's seat, diagnosing a patient, when the municipal workers arrived. They were in a foul mood as they rolled up their sleeves and descended into a trench filled with sewage. The trench, stretching across the Nankulabye slum in Uganda's capital city Kampala, was where the slum's [roughly 40,000 residents](http://askyourgov.ug/request/37/response/38/attach/2/Rubaga Municipality.pdf) dropped their waste: discarded cans, torn shoes, playing cards, cigarette butts, documents, sanitary napkins, and bags containing feces.
When it rained, the acrid water rose like a breathing thing, and so the city government sent their workers to empty the trench. On their last visit, the workers, who went in ankle-deep equipped only with gumboots, latex gloves, and shovels, had found a fetus wrapped in a polythene bag.
Businge, a 52-year-old nurse who runs her medical practice from a room across the trench, wondered how long it would take for the trench to fill up. About a week, she estimated. There were not enough toilets in the slum—each was shared by between ten and 50 people—and they were poorly maintained. If you had a school or office, you could wait to use the toilet there. But if you had to stay home and you were a woman, it was often easier to use a plastic bag at home and fling it into the trench. "We are falling sick every day," she said in Luganda. "But we are embarrassed to talk about these diseases we get from the toilets. We are ashamed."
"We are suffering quietly, but we are suffering a lot." –Businge
Women contribute critically to the success of sanitation programs worldwide, noted a study conducted by Sanitation and Hygiene Applied Research for Equity, consortium of five NGOs and academic institutions. "But the consideration of women and sanitation cannot focus solely on what women can do for sanitation," the report said. "It must also consider what inadequate sanitation is doing to them."
Businge diagnosed women from a table cluttered with diaries, a matchbox, a spatula, scissors, aspirin, a roll of bandage, and antibiotics. She could treat the physical discomforts, but had no cure for the anxieties her patients were tormented by: what would their husbands think, what did this disease say about them and their sexual practices, how shameful it was to contract a disease down there. "Hygiene is the only way to fight disease," she said. "But if they have a disease, they should not hide it because it can get bad. Even if they are scared their husbands will think they are unfaithful."
Each week, Businge, who trained at Nsambya Hospital, treats between eight and ten women with abdominal pain, malodorous discharge, itching, and vomiting, symptoms of urinary tract infections, and candidiasis, which she said came from exposure to pit latrines covered in feces, urine, and vomit. Sometimes they even come with intestinal and respiratory infections. The consultation costs 10,000 Ugandan shillings, or $3, less than the fee for a hospital visit. Over the past year, she has repeatedly treated herself for candidiasis, which she suspected she got from using a pit latrine she and her daughter share with at least 15 other families. "We are suffering quietly, but we are suffering a lot," she said.
In Uganda, only 19 percent of the population has access to improved sanitation (meaning a toilet that is not shared and has a mechanism that separates waste from human contact) according to the latest Demographic and Health Survey conducted by the Uganda Bureau of Statistics in 2011. The researchers from Sanitation and Hygiene Applied Research for Equity interviewed 32 women across three slums in Kampala, and found a "firm link between a lack of access to adequate sanitation and women's experiences of humiliation and violence." They mapped five trends—inadequate number of toilets, risk to safety, a deep sense of shame associated with lack of privacy, inadequate sanitation as a burden that fell largely on women, and a pervasive feeling of helplessness. "When an individual is deprived of their right to sanitation, they can also be deprived of their right to dignity, privacy, and safety," the report said.
Fatimah Nagawa, 18, will not use the communal toilet unless someone accompanies her. She will wait, or use a bucket at home, she said. In Wankulukuku, a slum on the boundaries of an industrial zone with about [16,000 residents](http://askyourgov.ug/request/37/response/38/attach/2/Rubaga Municipality.pdf), "There are many dangers," she said. "I feel harassed, I feel I will be attacked. Funny boys come there, they ask who is inside, and then they start to say stupid things like, 'What are you doing?' 'Can I come inside?' 'I love you,' 'I want to take your body.'"
Nagawa's mother was away through the day working for a tailor, designating her to care of her siblings Kasim, 12, Matridah, nine, and Zaharah, six. A year ago, a friend Nagawa had gone to school with said she had been raped inside a toilet here, and she had disappeared with her family almost overnight. "She could not stay here anymore," Nagawa said. "I think about where she is and I worry about my sisters."
Next door, Aminah Namujju, 36, was drying clothes on the floor in her home because it had been drizzling outside. Four-year-old Suleyman, her fifth child, was standing behind a curtain, calling out to his mother and hiding. Namujju said she could name at least ten women who said they had been assaulted in communal toilets in this slum. She did not know where they were now. "It is dangerous but when you have to go, you have to go," she said.
Namujju, like many in the slum, did not own rights to the land she lived on. She viewed building a toilet here as a pointless expense. "And it is a slumply area so whether you have your own toilet or not, it will overflow in the rains," she said.
Namujju, who ran a poultry business, lost her husband, a driver, two years ago. She now lives with her seven children. "It is embarrassing to go the hospital and say I am itchy down there even though I don't have a husband. They will wonder, 'How did you get it?'"
According to a 2012 study conducted by a team of six researchers, academics, and NGO workers from Kampala and Zurich, 78 percent of the people they talked to from 1,500 slum households shared a toilet with an average of six households. Of those, about 10 percent shared a toilet with up to 100 households. The researchers photographed 1,500 communal latrines and rated them for cleanliness, observing that 20 percent of them had considerable amount of solid material (paper, excrements, construction materials), big puddles, and liquids on the toilet, making it "difficult to use the toilet without getting dirty."
Grace Apiro was polishing her shoes at the threshold of her home in Kifumbira, a slum in northern Kampala, getting ready to leave for work. Someone had vomited in the communal toilet here the night before and she hadn't been able to step inside. "Only at times, they wash the toilet," she said. "When you go, there is no water inside, you have to pinch your nose."
Each visit to the toilet here cost 100 shillings, or 30 cents. Part of that money was supposed to go the janitor, an overworked man with pale skin and hooded eyes, who earned 50,000 Ugandan shillings, less than $17, every month to clean four toilets with only a broom, water, and disinfectant. But there were several days when he was too sick from cleaning the toilets.
"When it rains, the toilets overflow and we get fevers. When they fill up, cockroaches enter our houses and make us sick." –Evlin Kafero
The Kampala Capital City Authority (KCCA), the city government, was committed to improving sanitation in slums, having constructed about 15 toilets in informal settlements since 2012, Jude Zziwa, a spokesperson, said in an email interview. Community toilets in slums across the city's five divisions were emptied at a subsidized fee, garbage was collected for free, and drainage channels were cleaned, she said. "KCCA provides free toilet services at 18 places in the city (taxi parks, busy streets, and markets). The target population for this service is the transient population, part of whom come from the informal settlements," she added.
During Sanitation Week, which took place between March 12 and 18 this year, over 100 toilets were emptied across selected slums. "About 393,000 liters of fecal sludge were delivered. All the fecal sludge was from informal settlements," according to Zziwa. But maintenance of community toilets was the responsibility of committees nominated within slums, she said; the KCCA could only provide technical support.
Evlin Kafero, a midwife and the secretary of a women's group in Kifumbira, said there were gaps between policy and practice. Committees existed, but she said the burden to keep toilets clean fell on women like her. "If you hire a maid and you come back home to find she hasn't done her work, would you refuse to do it yourself because it is not your job?" she asked. "You will, because it is a hazard to you and your family. When it rains, the toilets overflow and we get fevers. When they fill up, cockroaches enter our houses and make us sick."
Kafero, who spoke in a soft, low voice, was sitting outside a grocery shop. This is where she had wanted to hold meetings to educate women about how to prevent diseases by soaking underclothes in salted hot water, buying underwear with cotton lining, ironing them before use, where to dispose sanitary napkins, how to clean a toilet. But getting women to come out when they could be working was tiresome. "They don't bother attending. They say it's a waste of time, it's too far, they are [too] tired to walk, they have become lazy. They don't think it is important," she said. And when she landed up at doorsteps, women who worried that her health campaign would turn into their husbands suspecting infidelity turned her away. "The mentality is not good," she said.
Betty Nyangoma, 25, was taking a lunch break from her job as the cook of a sidewalk restaurant selling beans and rice in Kifumbira. The problem with women, she said, was that they did not think about themselves. They suffered from diseases but did not do enough to alleviate their condition. "They think about everyone but themselves," she said. "They have their own thinking."
Nyangoma lived with her aunt and her four-year-old son, Jonathan in this slum, sharing a toilet with five other families. She had a diploma in hotel management but had been so far unable to get a job. "For me, I need my own toilet but if I don't have money, of course I don't have an option. Right now I have to focus on starting a new business, I have to think about my family and my son," she said. "But when I have money, I will have my own house and I will build my own toilet. That is my thinking."
Reporting for this story was made possible by the International Women's Media Foundation's African Great Lakes Reporting Initiative.
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