Schoolchildren drink tap water in Addis Ababa. Photograph: Sven Torfinn
Guardian Unlimited -- Ethiopians like to look spic and span. Whether in western suits or traditional white cotton shawls, their clothing is kept spotless.
The same cannot be said for the sprawling slums of Addis Ababa. In just over a century, Ethiopia's capital has grown from a royal village founded by an African queen to a metropolis of over 3 million people. The poorest, most densely populated quarters of the city have expanded too rapidly, and with too little planning, for basic services to keep pace.
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Rahima Abagado does her best to keep her children clean, but for years she fought a losing battle. On the other side of her living-room wall was the neighbourhood's communal latrine.
"This is where the children used to sleep," Abagado says, pointing to mats on the floor by the wall. The blue, plastered wall looks cracked and weak, and there is a faint, dank smell. "The latrine used to fill with water. It used to smell from underneath. There would be water running off into the street. The wall was soggy and we were worried that it would collapse."
Abagado, a grandmother in her 60s, lives in the tightly packed quarter of Tekle Haymonot, in a two-room shack of mud, plaster and rusting iron sheets. Outside on the cobbled street, chickens peck at the dirt, cats wander between the houses and children play. The children are forbidden to use the communal latrines, for fear that they will fall in. The latrines are wooden huts, built over vast, dark pits, with shaky wooden slats to stand on. There are buzzing clouds of flies circling the holes.
"Addis is a storeroom of diseases," said Bedria Ahmedin, 40, a mother of six. "People have to go to the toilet and that exposes us to diseases. We try to keep the area outside the toilet clean, but children touch things, put things in their mouth."
Poor sanitation has deadly consequences. There is increased susceptibility to water-borne diseases such as diarrhoea and dysentry, as well as the eye infection trachoma and scabies, a skin infection.
In countries such as Ethiopia, diarrhoea is not just a nuisance; it accounts for 46% of mortality among children under five. For people living with HIV, lack of sanitation creates further problems. Wubiye Bekele, a 28-year-old woman who found out she had the virus two years ago, says: "I've had TB, skin problems, and swellings of my lymph glands.
"We used to have just a pit latrine, but then it burned down. So I either have to ask the neighbours or use a night potty, and dump it in an open sewer. While I had TB I had diarrhoea and had to go to the toilet a lot more. I need more water for washing myself, and also for drinking."
Ethiopia has some of the lowest levels of sanitation in the world. Only a tiny fraction of the population in Addis Ababa, just 3%, have flushing toilets linked to the sewer system.
There are a variety of alternatives; for nearly a quarter of the city's people, the solution lies in the streams running through poor areas, which have been turned into open sewers.
Others use pit latrines, of the old-fashioned, hazardous and filthy variety, or sometimes a safer, modern version built by an aid agency. If they have enough money to build one, some have their own septic tanks at home.
"The bulk of the population in Addis is not in a position to pay for such [sanitation] services," says Mesfin Tegene, Ethiopia's deputy minister for water resources.
"Addis has a population of 3 million-plus. The great majority of the population lives in poverty so a few people, a small percentage of this population, can afford to pay for such services."
Sanitation is a Cinderella service. Everyone knows they need water, and even the poorest are prepared to pay for it.
But the costs of poor sanitation - the increased risk of disease and the environmental damage - fall more heavily on society as a whole than on the individual. So few poor people are prepared to pay.
"The impact of bad sanitation is more long-term," says Abebe Belete, deputy general manager of Addis Ababa Water and Sewerage Authority. "The pollution for example, from liquid waste disposal, pollutes the environment in general, the soil, the vegetation. But there is a natural process - the ecosystem tries to recover itself, you many not notice the immediate effect.
"People think more about getting food or water, rather than considering [that] their child is going to be affected or [how] it's going to cause other detrimental effects for the next generation to come."
Even with the public and political will to build a better system, there are big practical challenges. First, a sewer system requires flushing toilets, because the waste is flushed through the system with water. And that requires plentiful access to water. The second difficulty is the expense of building the sewer lines themselves. The system depends on gravity rather than pumping, so the sewer lines do not necessarily take the shortest route.
"Because of gravitational flow, the system has to be very perfect," Mr Belete says. "It may take a longer time to deliver it to the treatment centre.
"In flat areas we have to pump, and pumping is very expensive, because it has to handle solids combined with liquid, that makes it more expensive compared to the water supply."
The parts required for engineering work are imported either from Europe or the far east, increasing the expense.
The doubling of aid could clearly make a difference here. The levels of aid going into Ethiopia now are low by comparison with other sub-Saharan African nations: in 2001, it was $16 per person, compared with $33 in Burkina Faso.
But there are delays in spending the aid money that is already coming in. According to the British charity WaterAid: "In the water sector, these delays arise from lengthy tender procedures and even repeated losses of paperwork."
Spending can be poorly coordinated, WaterAid says. Some donors prefer to spend their money directly at regional level, rather than going through a ministry, but this can mean that an equivalent amount is simply deducted from that region's central government grant.
The way that some donors choose to spend their aid money can cause further problems. Some aid grants are hedged about with conditions that require the Ethiopian authorities to hire consultants and contractors from the donor country.
Mr Belete says: "Their companies build up their own overhead costs, pay expatriate salaries. Sometimes the amount of money required for a project may be more than double our assessment."
The excess has to be found from Ethiopia's public coffers.
"In some cases [aid] is beneficial," Mr Belete says. "But in some cases it can take more money from us, and we do not benefit from the grant."
Making Addis cleaner and healthier is not always a question of vast projects requiring millions of aid dollars. A far more small-scale initiative is making a big difference in Tekle Haymonot. Every morning, just after dawn, gangs of women and men dressed in long gowns and face masks go out to collect household rubbish - a mix of ash from cooking fires, vegetable peel, bones and chewed up qat leaves which might once have been tossed into a river or dumped in a street corner.
Households pay a small fee, between two and four Ethiopian birr [12p-25p] a month. The narrow streets, where women wash their clothes in steel drums and dogs sun themselves on the steps of houses, are largely clear of rubbish now.
Asnaku Mamo, 35, a mother of two, says: "There have been lots of changes. Our children get sick less often, and there is more of a sense of cleanliness in our environment. Everybody used to leave their rubbish out. It was unsanitary and unhealthy. Everybody knew this and did nothing about it.
"We're not spending so much money on medication. You had to spend 100 birr taking a child to the doctors, compared with spending a few minutes a day or a few minutes a week to clean in the environment."
As well as collections of household rubbish, there is a communal clean-up of the streets every Saturday morning. Each household is responsible for clearing the space outside their front door.
Some people fail to pull their weight, though others have been spurred to display signs of new-found communal pride; there are tiny box gardens by the doors of some houses.
Zehara Bashir, 38, one of the rubbish collectors, says: "There are changes coming, really good changes, but some people just chuck rubbish in the river and that undermines everything. People say, 'Why do I bother paying? Why don't I just chuck things in the river as well? ' It's important that everybody does it. Otherwise we still have a problem."
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