Silhouettes slip along narrow paths, farmers heading to their gardens, women balancing yellow jerrycans on their hips, children in oversized sweaters hurrying to school, and herders steering cattle toward open pasture, each movement part of a choreography older than memory. This is a quiet ritual in Kabale’s terraced hills, moments before the sun lifts.

The quiet procession to ahakashaka, or omukishaka, often sees figures moving quickly along familiar footpaths in the half-light, as children and adults walk with the urgency of habit. It is not a stroll but often a small, hurried run before daylight exposes what should be private.

It is February 2026, and the century-old Makerere University is celebrating its 76^th Graduation Ceremony. The world paces and races toward artificial intelligence and digital revolutions. But some families still begin their day by rushing to the bushes for relief and concealment, while others engaged in economic activities such as gardening and grazing have no sanitation option other than using their surroundings to respond to the nature call!

The deadline to end open defecation is 2030. The science is settled, and the commitments are written into Sustainable Development Goal 6. Yet in parts of Kabale, only a small fraction of households is truly open defecation free.

In his PhD research, Dr. Moses Ntaro did not start with global targets or conference declarations. He began where the morning run ends, at the edge of the compounds, behind banana stems, along worn paths leading to Omukishaka. He asked whether students, equipped not with bricks but with conversation, follow-up, and persistence, could help communities replace that dash with something quieter: a door that closes.

What he found is both hopeful and unsettling. Change is possible. But dignity, like sunrise, should not require a run. And with 2030 approaching, time is no longer generous.

The Question That Would Not Let Him Go

Ntaro did not encounter open defecation as a statistic. While on foot and serving as Assistant Coordinator of Community-Based Education at Mbarara University of Science and Technology (MUST), he learned while supervising students placed in rural communities across southwestern Uganda. They walked villages together, conducted transect walks… and they observed.

“In my role as academic coordinator,” he explains, “students always took me on transect walks within the villages to show me how high open defecation practice was. The effect was evident in the high prevalence of intestinal infections we saw in health facility records.”

The link between sanitation and disease was not theoretical but visible in clinic registers. Diarrhea, intestinal worms, recurring infections among children, and more were all visible in the clinic registers.

Nineteen years ago, in 2007, Uganda adopted Community-Led Total Sanitation (CLTS), a strategy designed to trigger collective behavior change and eliminate open defecation. Progress, however, remained uneven. That same year, Ntaro was working as an Environmental Health Officer with the Water and Sanitation Development Facility under the Ministry of Water and Environment. He was three years away from completing his Environmental Health degree at Makerere University School of Public Health.

And so, the question emerged, to Ntaro, that, ‘If students are already embedded in these communities through COBERS placements, why are we not intentionally harnessing them to accelerate sanitation change?’

That question became his PhD.

This is a Crisis That Should No Longer Exist

Globally, more than 350 million people still practice open defecation. Sub-Saharan Africa carries a disproportionate share. SDG 6, specifically Target 6.2, commits the world to ending open defecation and ensuring universal access to safe sanitation and hygiene by 2030. It prioritizes women, girls, and vulnerable populations. It speaks of dignity, of safely managed services, and of disease prevention.

We are four years away from that deadline. And in rural Kabale District, somewhere in southwestern Uganda, Ntaro’s research found that only 3 percent of households were truly open defecation-free.

Yes, three percent. His 2025 BMC Public Health study examined 492 residents. The average age was 49. Nearly 30 percent had no formal education. Most were women, the custodians of household hygiene and child health.

The determinants of Open Defecation Free (ODF) status were deeply behavioral.

Male-headed households had higher odds of being ODF. Households with clean compounds, clean latrine holes, and consistent handwashing practices were significantly more likely to sustain sanitation improvements.

Sanitation, Ntaro realized, is not only infrastructure but also power, memory, habit, and social expectation.

“Factors associated with ODF status were not just economic,” he notes. “They were behavioral and contextual.”

Why It Feels So Wrong to Still Discuss This

Talking about open defecation in 2026 feels unsettling for three reasons. First, it feels like a failure of basic dignity.

Think of an era of global connectivity and rapid technological advancement, and hundreds of millions still lack privacy. For women and girls, this exposes them to harassment, exploitation, and fear. Sanitation is not just about disease but safety.

Second, it feels like an avoidable health crisis. One gram of feces can contain millions of viruses, bacteria, and parasites. Open defecation directly fuels cholera, typhoid, diarrhea, and environmental enteropathy, a silent contributor to child malnutrition and stunting. The science is settled, and yet the practice persists.

Third, it feels like a poverty trap. Illness leads to lost productivity; lost productivity deepens poverty, and poverty limits investment in sanitation. The cycle continues.

“Open defecation is not simply a sanitation issue,” Ntaro says. “It is linked to poverty, nutrition, and broader development.”

Testing a Different Approach

Ntaro’s doctoral thesis, “Effect of Student Community Engagement on Open Defecation-Free Status,” tested whether health profession students could effectively facilitate Community-Led Total Sanitation.

In some villages, traditional Health Extension Workers led the sanitation process. In others, trained students facilitated it under the COBERS (Community-Based Education, Research, and Service) model, which places medical trainees in community health facilities to learn through real-world practice, bridging classroom theory with primary care and public health work in rural settings.

Through this model, students led triggering, follow-ups, and community engagement. Open defecation declined. More households achieved Open Defecation Free status. And the cost per household was lower than in traditional approaches.

“Students were more effective,” Ntaro explains. “More households became open defecation-free compared to the traditional approach. And they were a cheaper human resource.”

But cost was not the real breakthrough. Presence was. Students stayed for weeks. They returned to check on latrines. They built trust. They kept coming back. Because sustainability, Ntaro argues, is not built in a single visit. It is built in repetition.

“There is a need for continued follow-ups and continued student engagement if long-term impact is to be realized.”

Change cannot be declared once and forgotten.

Behavior… and Not Just Bricks

Using the RANAS framework, Ntaro found that households that remembered to wash hands and kept latrines clean were far more likely to sustain Open Defecation Free status. In sanitation, behavior leaves evidence.

“Behavioral change interventions that empower communities,” he recommends, “such as CLTSH, should be strengthened to increase households with ODF status.”

In other words, building latrines is not enough, but communities must believe in them.

The Defense and the Countdown

On December 11, 2025, Ntaro defended his PhD. Examiners pressed him on scale and sustainability. Could student engagement be institutionalized? Could universities be embedded in district sanitation planning?

His answer was pragmatic: “Yes, but community-based education must be included in planning and budgeting.”

Four years remain to meet SDG 6.2. Four years to end open defecation and turn dignity from promise into practice. In 2026, this conversation should feel outdated. Instead, it remains urgent.

The Slow Work of Restoration

In Kabale, progress does not look dramatic. It looks like a latrine door closing firmly behind someone, a handwashing station with water and soap, a compound swept clean. It looks like a child who does not fall ill this month. Public health victories are often quiet.

As Makerere University approaches its 76th Graduation Ceremony, Dr. Ntaro Moses stands among its PhD graduands not with theory alone, but with evidence that change can be accelerated by reimagining who leads it. Students, he shows, are not only learners. They are the workforce, facilitators, and bridges between policy and path.

The hills of Kabale still wake under mist. But in more compounds now, privacy exists where bushes once stood open. Dignity is not restored in headlines, but one household at a time.

And with 2030 approaching, Ntaro’s work leaves a final, unavoidable question: if we already know how to end open defecation, if we already have the tools, the evidence, and the people, what, exactly, are we waiting for?

— Makerere University School of Public Health Communications Office, Graduation Profiles Series, 76^th Graduation Ceremony

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