Education and Sanitation: Decreasing Diarrheal Diseases in Gambella Camp, Ethiopia.

South Sudan became the world’s newest country in 2011. Since then, nearly 3.6 million people
have fled South Sudan due to political unrest and tribal rivalry (1). Many remain internally
displaced, while others are now refugees in surrounding countries such as Uganda, Ethiopia,
and Kenya. In this region of Africa, diarrheal diseases are the second leading cause of death,
accounting for nearly 8% of total mortalities (2). Diarrheal diseases are also the primary cause
of child mortality (3). Only 37% of mothers in the southern region of Africa were found to have
adequate and accurate information about how diarrheal diseases spread. This lack of education
increases disease risk (4). In refugee camps, even higher rates of diarrheal diseases have been
observed due to decreased sanitary conditions and increased population density. In cases of
diarrheal disease mortality, 88% are due to either poor hygiene and sanitation or unsafe water
(2).

There has been extensive research into effective methods to reduce, control, and prevent
diarrheal diseases. Research has been focused on improving sanitation conditions in refugee
camps throughout Africa, through methods such as providing soap rations, improving waste
disposal systems, and improving water access (5). There have also been attempts to effectively
and efficiently provide treatment to patients already diagnosed with diarrheal diseases (6). By
combining methods of treatment, prevention, and education we will be able to decrease
diarrheal disease rates in the Gambella refugee camp in Ethiopia with a total of 397,000 South
Sudanese refugees (7).

Aim 1. Provide sanitation stations that will include cement stalls, pit latrines, clean water, and
soap to the Gambella refugee camp in Ethiopia. We will reduce the spread of human waste
and diarrheal diseases in the camp by providing proper infrastructure. We will also be Providing
soap and access to clean water will increase sanitation and decrease the incidence rates of
diarrheal diseases.

Aim 2. Institute short 15-minute educational sessions informing refugees how to properly use
sanitation in the camp. Sessions will include details on preventing diseases for which refugees
in Gambella are most at risk. We will instruct on the proper use of soap and clean water after
using the restroom. We will also provide instructions and materials for making soap so that
there is a sustainable supply for residents of the camp.

Aim 3. Isolate patients that are infected with diarrheal diseases to prevent further spread
among the camp population. With the goal to decrease the further spread of diarrheal disease,
we will provide a medical tent for those who are infected to receive treatment. By separating
the sick from the healthy we will decrease transmission. Individuals will be isolated and treated
through oral rehydration and careful monitoring until conditions improve.
1. Background

1a. History of Refugees going from South Sudan to Ethiopia

Two years following South Sudan’s independence in 2011, violence arose from conflict
between different government parties and began to affect many of the citizens (1,8). Because
of this civil unrest, famine and poverty have swept the country, leaving 100,000 people with
severe lack of food. The new economic structure enabled economic inflation to increase by
835%, decreasing the population's ability to buy and sell needed goods. One third of South
Sudan’s population has become displaced due to the famine, poverty, economic crash
and violence. Pillaging has become commonplace, and violent thievery has caused the
migration of people out of their nation. Currently 6 million people do not have enough food,
and 4.5 million are in need of other goods like shelter and hygiene goods. Disease has
accompanied the crisis and over 13,000 people have been affected by cholera outbreaks. The
newness of this nation has added to its issues. With violence emerging early on, economic
stability was not achieved before the social and economic issues arose. More than 50% of South
Sudan was and is living in conditions considered absolute poverty (1). Ethiopia is one of the
nations that border South Sudan, and has become a new home for 352,409 of these refugees
(1,7).

1b. Diarrheal Diseases among Displaced persons

Due to situations of war and civil unrest, refugee camps hold anywhere from 200 to 200,000
displaced persons in a concentrated area (7,9). Ethiopia and South Sudan are homes of several
refugee camps, like the Gambella camp which has several settlements of various sizes (Pugnido
II- 17,237, Okugo- 8,428, Pugnido- 18,187, Kule- 53,010, Jewl- 59,761, Tierkidi- 71,090) (7). This
congestion allows for diseases to spread with ease. In these camps there are often not enough
resources to adequately supply each individual with necessities to remain disease-free. One
reason for this is water scarcity. Most refugees enter the camp in large families but with
insufficient supplies to support the number of people (1). There is not enough clean water to
bathe in, wash clothes with, and consume, so refugees end up drinking unclean water which
raises their chances of getting diarrhea caused by bacteria and viruses. (6, 9). Nearly 60% of
displaced people are children who have not developed a strong immune system (10). An
underdeveloped immune system accompanied by lack of nutrient rich food in the camps
increases children’s risk of diarrheal diseases over adults (3,10).

1c. Causes of Diarrheal Diseases

Consuming unclean water is the major cause of diarrheal diseases (4,6,11). People who used
water regularly from unprotected sources are 8 times more at risk than those using safe
sources (4). Open defecation and lack of restroom facilities increases the rate of spread 3.34
times (3,6). PoMany diseases, like cholera and giardia, cause diarrhea in patients (12).
Salmonella enterica, and Escherichia coli are bacteria that when consumed cause diarrhea.
Most causes of diarrhea are caused by fecal matter entering the digestive system (10).
1d. Geographical distribution of common diarrheal diseases
Countries that have lower average income are more susceptible to diarrheal diseases which
makes it extremely prevalent in refugee camps (3,13). Lower income can correlate with
decreased access to clean, sanitized water (4). Due to weaker immune systems and
malnutrition, children in these areas are heavily impacted by diarrheal diseases (3). Populations
in urban areas are 31% more susceptible to contracting these diseases than rural areas (6).
Ethiopia, Kenya, Uganda, and other countries in this part of the world have heavy and frequent
rainfall which prevents water from remaining sanitary and increases the rate of disease (1).
There is often standing water for days which breeds bacteria and viruses that people begin to
use to wash clothes and bathe in. In desperate cases when no other source is available this
water is also consumed (1). Depending on the part of the world, certain diseases are more
prevalent than others. A list of several bacterium, parasites and viruses that cause diarrhea in
Africa are Leptospirosis, Hepatitis A, Hepatitis E, Vibrio cholerae, Vibrio parahaemolyticus,
Shigella dysenteriae, and Rotavirus (14,15,16).

Extreme poverty is abundant in Africa (15). Poverty decreases ability to receive health care,
nutritious foods, and often means living conditions are below average. This increases
susceptibility to diseases (13,15,18).

1e. Signs and Symptoms of Diarrheal Diseases

Gastrointestinal pain and cramps, fever, fatigue, soft stool, bloody soft stool, and soft or liquid
bowel movement 3 times a day, are all symptoms of diarrheal diseases (10). The side effect of
dehydration can become severe enough to cause death (3,4,10). Children who have a diarrheal
disease have an 11% chance of mortality. Diarrheal diseases are the highest cause of mortality
and morbidity for children age five and younger (3,6).

1f. Common Prevention Practices and Treatments

Homes that allowed for proper hand washing reduced infection by double the amount
compared to those homes without (3). Rates of diarrheal disease decreased by 45-48% in
studies that analyzed the effects of handwashing with soap and proper education of how to do
it (9,10). When proper disposal of human waste products, either in a latrine or burying of
waste, occurs and clean water is available the risk for disease drops from 17% to 38% (9,10).
Mercy Corps, an organization working alongside the United Nations (UN), has helped prevent
over 50,000 refugees from contracting diseases like cholera. This was done by supplying hand
washing stations as well as urination and defecation facilities (1). The Bill and Melinda Gates
Foundation is funding the building of latrines in areas similar to Ethiopia. This enables feces to
be contained in a safe area that less likely to leak and infect others (17). Infected individuals can
also be isolated with hospital surveillance to prevent spreading and better contain
contaminated feces (9,10,15).

In a study conducted on awareness of diarrheal diseases mothers frequently know how

diarrheal diseases are spread and how to best help the members of their family who have
contracted the disease. However, most cannot tell when their children are dehydrated and
thus do nothing to help combat this symptom. Culturally as the chief caretaker of the family,
mothers are the ones who care for their sick children (4). The education of mothers affected
children’s susceptibility to contracting diarrheal diseases (18). 38.8% of mothers believed
giving their child liquids would make their child sicker and only fed them dry foods like bread
and coffee powder. In studies where mothers were educated on how to better take care of
their sick family members the rates of diarrheal disease decreased by 3.6 times. When mothers
realized the severity of someone contracting a diarrheal disease they were 62.4% more likely to
take that person to see a healthcare professional. This allowed them to receive professional
health to avoid morbidity and mortality (4). Increasing proper nutrition, vitamin supplements,
proper home sanitation and would lower the death rate of diarrheal disease by 22% (15).

Another study tested Rotavirus vaccines on children under the age of 5 to test for resistance
against diarrheal diseases. Appearance of rotavirus in diarrhea decreased by 20% over 5 years.
Although this vaccine was effective in lowering rotavirus, cases of diarrhea actually increased by
almost 2,000 (16,18). There is a chance that other pathogens are becoming stronger in causing
diarrhea (16). In order to completely eradicate diarrhea, a vaccine for each virus strain found in
diarrhea would need to be made and distributed to everyone who is at risk (16,18). Carrying
vaccines to less developed areas, like many refugee camps, is difficult as well. High costs,
difficulty in transporting, and lack of cultural support makes it unlikely that vaccines will be
brought to these areas (18).

2. Innovation

Aim 1:
Previous programs have been implemented to prevent and control the rates of diarrheal
disease in Sub-saharan Africa. One program conducted in a refugee camp in Malawi provided
soap rations to the residents of the camp. They saw that the effects were beneficial and the
rates of diarrheal disease decreased. We chose to use our approach rather than this one
because ours also includes providing clean water access and better infrastructure, which the
lack of have been seen to be risk factors in diarrheal disease exposure. Having some place
refugees can defecate will decrease the amount of contact others have with feces. It will also
discourage people from using rivers and other water sources as a bathroom, which would
contaminate the water from which people normally use to wash clothing and bathe in. This
approach will also give the refugees in the camp a chance to work and have a small income.
Due to displacement from their home villages and workplaces refugees frequently have little to
no income to provide for their families. Providing even a small income has the possibility to
improve the livelihood of those living in Gambella (12).

Aim 2:
Refugee camps located in neighboring countries have implemented similar programs where
sanitation was encouraged. Soap was dispensed to refugees in Ethiopia, Kenyan, and Thai
camps, however, education on the proper use of soap was not given and refugees prioritized
using soap for laundry over hand cleaning (14). In the Gambella camp we desire to educate the
refugees foremost on the risk of transmitting disease if proper sanitation is not performed.
Furthermore, we want to teach the proper use of the soap is for hand sanitation. Unlike other
camps, we will accomplish this with 15 minute educational sessions where a healthcare worker
will educate groups on the risk of disease and the proper way to avoid disease transmission
with hand sanitation. Unique to our camp will also be educating on soap production. We will
teach the refugees how to make soap so they won’t be dependent on outside sources. We will
also monetarily compensate the refugees who make the soap. This approach will give refugees
a skill while also encouraging them to keep a constant supply of soap in order to receive pay.

Aim 3:
In similar locations, other camps have implemented vaccination programs alongside their
medical treatment (17). However, vaccines are only made for Rotavirus and Cholera which still
allows incidence rates to remain high. Vaccines and certified administrators are expensive and
difficult to obtain in refugee camps and vaccinations without sanitation measures can still
spread the disease. In the Gambella camp, oral rehydration therapy will be the primary
treatment method accompanied by isolation, because it is more affordable and sustainable
compared to vaccinations. Patients who receive oral rehydration will be able to regain energy
from necessary electrolytes they lost while sick. Research in similar camps show that the
recovery rates are over 90% if they are moved to a medical facility and given treatment (19).
Sanitation and isolation, especially in the medical tents, will be the most effective prevention
method for the camp. Isolating patients in the medical tent will help to reduce spread of the
disease while they are receiving their oral rehydration treatment.

3. Approach

Before beginning our approach, we will contact the camp leaders and local government. We
will be partnering with the local government who will slowly integrate into our program over
the five-year period and take over when we leave. Local camp leaders will designate areas for
us to set up stations, build tents and dig trenches as well as give information and data regarding
the camp’s needs. We are partnering with local organizations who have contractually
agreed to assist with funding for the medical tents and supplies.

3a. Aim 1: Provide sanitation stations that will include cement stalls, pit latrines, clean water,
and soap to the Gambella refugee camp in Ethiopia
Our goal is to establish functional sanitation stations to provide clean water and soap to
promote cleanliness and decrease transmission of diarrheal diseases. We will provide new
infrastructure to reduce the spread of contamination. We will also encourage the use of the
new facilities, and educate individuals on sanitary practices, especially hand-washing. We will
implement these measures in Gambella Refugee Camp, Settlement Pugnido II, located in
Ethiopia. Dr. Brooke Carroll, MPH, MD, will be in charge of supervising and implementing these
changes. Dr. Nancy Aleccia from the CDC will assist Dr. Carroll in supervision.
In order to accomplish our goal, we will
have many different employees helping
with different aspects of the daily
operations. We will hire an infrastructure
project manager who will be in charge of
recruiting workers and volunteers, and
overseeing the construction of the
infrastructure for the latrines (see figure
1). The construction workers who will
perform the manual labor for the latrines
and handwashing stations will be locals or
refugees from the camp. We will also hire
a sanitation manager who will be in charge
of maintaining clean water and soap
supplies at the hand washing stations. Figure 1: Latrine design
This will be one of our in-country health workers. In order to provide job opportunities for the
refugees living in the camp we will hire a team of refugee workers to make the soap.

The health workers will be responsible for organizing the necessary supplies for each hand
washing station and teaching the refugee employees how to make soap. Each week a family, or
group of families, will be assigned by a health worker to clean the latrines and insure that they
are sanitary. The settlement we have chosen to work with has 17,000 refugees. We will provide
85 sanitation stations to be distributed throughout the premise of the camp to ensure that all
residents have access to a station. Each of the 85 sanitation stations will have 10 stalls. 50
volunteers will be needed to help with the manual labor of the construction and maintenance
for the sanitation stations. We will evaluate the success of the sanitation and washing stations
by having those who use them document their usage. We will also administer anonymous
surveys to see if the sanitation stations are being overcrowded during certain times of the day
or to see if there are any changes we can implement to make them more sanitary and effective.
We will use surveys, both quantitative and qualitative, over the 5-year period to get feedback
on usage, diarrheal disease rates, and user satisfaction.

3b. Aim 2: Institute short 15-minute educational sessions informing refugees how to properly
use sanitation in the camp.
In order to maximize the effectiveness of the latrines and sanitation stations built, we will hold
educational sessions for refugees. Dr. Katie Angerhofer will be the head supervisor over the
creation and execution of the sessions taught. Working closely with natives and health care
workers from refugee camps in Ethiopia, Dr. Angerhofer will formulate 15 minute sessions on
proper sanitation. Each session will teach on the proper use of soap, the process of making
soap, and proper techniques for hand sanitation. Each session will be led by a trained sanitation
manager. We will assemble the refugees in groups of 20-30 people. Healthcare workers will be
able to answer any questions and model correct hand sanitation. We will hire 3 natives that
speak English and Amharic to be teachers and work as translators for health workers. Dr.
Angerhofer will train these teachers how to instruct the classes. We will have our teachers run
classes whenever new refugees arrive.

Each session (15 minutes in duration) will be broken down into subsections. The first portion of
the course will cover the risk of diarrheal disease transmission in the camp. This portion will last
about 2 minutes and lead to a short 5-minute discussion on the importance of proper hand
sanitation and demonstrations of proper cleaning. This portion will also cover techniques on
using soap to effectively clean the hands. We will then give a brief explanation (3 minutes) on
where and how to get clean water. Throughout this portion of the session, we will have health
care workers modelling how to use the soap and clean water. We will also show how to purify
the water. The second half of the session (6 minutes) will be teaching refugees how to make
soap.

A healthcare worker will introduce all of the ingredients used to make soap and then we will
have the workers hold a demonstration making the soap. Throughout this portion we will set a
clear expectation that the soap’s sole purpose is for hand sanitation and not laundry or
body hygiene. After the session is over we will have sign-ups for those who are interested in
making soap. After we have around 60 refugees signed up for the soap making stations, we will
assemble a schedule of shifts. We will run one shift a week for 15 workers, and each worker will
be given one shift each month.

These sessions will take place near the sanitation stations dispersed throughout the camp. We
will set up a seating area outside of the stations. We will hold the classes in the seating area to
familiarize the refugees with the latrines, resources available, and how to use the facilities
correctly. Each station will have bulletin boards with step by step diagrams showing proper
hand sanitation. However, we will also post fliers and diagrams of information shared in these
courses on bulletin boards in the tents. Our vision for placing the fliers here is to remind
refugees who are infected the proper techniques to avoid further infection or transmission. On
all bulletin boards we will also include schedules listing when specific families are assigned to
attend the class. We will also offer make-up or refresher sessions where anyone is welcome, up
to 30 people per session. As refugees join the camp, they will be assigned to classes.

To monitor the effectiveness of our classes we will do a quiz at the end of each session asking
simple questions about the techniques taught. We will also collect individual health data from
those who have attended the course. We will send health workers to collect the data using
short questionnaires about general health over the past few weeks. We will measure for
diarrheal disease rates and focus on clusters of people with more incidences. Our focus will be
teaching these clusters how to sanitize properly at the sanitation stations.

A large part of the work will be done at our headquarters in Ethiopia. Additional work will
happen in the United States, including: printing flyers and posters, preparing presentation
materials for classes, and assembling ingredients for soap making stations. We will take the
materials with us as we travel from the U.S. to Ethiopia.
 3c. Aim 3: Isolate patients that are infected with diarrheal diseases to prevent further spread
among the camp population.
In the Pugnido II camp, there will
be 15 designated medical tents,
secluded from the housing tents
(See Figure 2). Each tent will
contain an isolated critical care
area, 50 medical beds accompanied
by bedpans and bednets. Tents,
beds and supplies will be funded by
the organization we partnered
with. Tents and sanitation ditches
will be set up by paid locals in the
camp and trained, paid volunteers
from outside the camp who have
received detailed instructions on Figure 2: Locations of medical tents and housing area
where build. Sanitary ditches will
be dug by the paid personnel 10ft deep, 10ft wide, 30ft from each tent, and rimmed with
cement to prevent flow back into the camp. Paid medical professionals, along with local
certified medical volunteers will work as medical providers for the camp tents. There will be
one lead over all the tents, and one paid professional accompanied by ten volunteers per
medical tent. Dr. Ludlow, epidemiologist, will be the lead professional over this project.

Volunteers will identify patients who are infected with diarrheal diseases and then separate
critically infected patients into an isolated, critical care area of the tent and assess their
condition. Triage will be based off of height and weight for age, how long the patient has been
showing symptoms, and how dehydrated or malnourished they are. Those who show more
severe symptoms will stay in the tent where immediate treatment and increased surveillance
will be given. All patients suffering from diarrheal diseases will be treated by volunteers with
oral rehydration packets and will be monitored throughout the day. Medical professionals will
check on patients and administer oral rehydration if needed. Oral rehydration will be prepared
and delivered by professionals who will make sure the patient finishes each dosage. They will
chart patient data, including incidence and mortality rates and report back to the lead
supervisor, Dr. Ludlow.

Volunteers will clean and sanitize areas and bedpans where sick patients are located to reduce
the spread of diarrheal diseases. Cleaning will take place in a designated trench area outside
the tents where contaminants will be unable to drain back into the camps. Sanitation materials
will include: clean water, bleach solution, and reusable cloths and brushes. Sanitation will be
done on all beds, pans and medical supplies. If family members wish to visit those in isolation,
volunteers will assist them by dressing them with protective masks and gloves so they don’t
contaminate the camp when they return.
Supplies will be obtained and distributed to each tent by Dr. Ludlow. Supplies are bought by our
organization as well as donated through outside organizations and partnerships. Cleaning and
sanitation supplies will include, three pump sources per tent of clean water separate from the
sanitation stations, 50 gallons of bleach per tent, and 20 large bags of cloth per tent. Each tent
will be supplied with 1,000 rehydration packets. Dr. Ludlow will take inventory of supplies and
study prevalence of disease every two weeks. Depending on the inventory and prevalence in
the tents, Dr. Ludlow will either purchase more, or implement rationing of supplies based off
the data collected. Tents, beds and supplies will be continuous throughout the five-year period
to combat diarrheal disease along with new epidemics. The number of patients coming to the
tent to receive treatment will be documented to evaluate effectiveness. We will keep records
of the incidence and prevalence rates of diarrheal diseases in our camp and compare the data
over the 5-year period. We will know we are successful if the numbers decrease by over 50% in
the 5-year timespan.

4. Timeline
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