Outside Kenya's biggest slum, one-year-old Michelle Wabuira sits silently in her mother's arms, her eyes sunken and struggling to keep her head up. She has diarrhoea, the second biggest killer of children under five.
Michelle is one of millions of children who will get diarrhoea this year, nearly a fifth of whom will die. That's 1.6 million children killed every year by what aid workers say is an entirely preventable disease.
Two major aid agency reports published this week say millions of children's lives are being put at risk because governments and the international aid community are not responding appropriately to diseases such as diarrhoea.
"Diarrhoea kills more children than HIV/AIDS, malaria and TB combined, yet compared to these diseases receives little financing and is not prioritised by governments in donor and developing country governments alike," said Oliver Cumming, co-author of a report by Water Aid.
The report shows that between 2004 and 2006 only $1.5 billion was spent globally on improving sanitation. In the same period, $10.8 billion was spent on interventions for HIV/AIDS - responsible for 315,000 child deaths in that period, and $3.5 billion on interventions for malaria - responsible for 840,000 child deaths.
Kenya's Red Cross emergency health manager James Mwangi says outbreaks of diarrhoeal diseases are due to lack of access to safe water, poor sanitation and unhygienic practices.
"The same community are using the water for livestock drinking, for washing clothes and some community members also bathe in the same rivers. It is a full cycle with problems related to water sanitation, hygiene and of course knowledge," added Mwangi.
HEALTHCARE
A health worker in the only government-run clinic in Kibera said diarrhoea was a major problem in the slum, which is home to over one million of Kenya's poor. It's easy to see why - toilets are holes in the ground and many are overflowing.
"There are a lot of cases of children dying of diarrhoea because the health service in a slum setting such as this is not so well distributed," added the health worker who asked to remain anonymous.
She said most clinics in the slum were private and the majority of people could not afford the fees. The lack of roads, lighting and poor security also made it difficult to reach a doctor, particularly if a child fell sick in the middle of the night.
"By the time this child is brought to hospital maybe it is too late, the intervention of what could have saved the child is overtaken by time and events and we lose that child," she added.
Michelle Wabuira's mother Rosla said she arrived in Kibera last week from her home in Busia, in Kenya's Western Province. She believes her daughter fell sick after drinking water from a tank.
"I don't know if the water is clean, we don't even have Water Guard (a brand of water purifier)," Rosla said. "Because of diarrhoea I have decided to go back to Busia because here, hygienically, I don't feel safe."
BURDEN
Another report "Diarrheal Disease: Solutions to Defeat a Global Killer" by health advocacy group PATH, speculates that in the 1970s and 1980s awareness-raising and fund-raising for tackling the problem were so successful that the mortality rate fell by almost 50 percent. It says many donors, governments and aid agencies may have considered the problem solved.
But the issue is far from solved. Water Aid says that when taking into account adult deaths, funding for HIV/AIDS is balanced, but when considering child deaths, the large resources for fighting the disease are disproportionate.
Both reports highlight that relatively cheap fixes can be effective - for example educating people to wash their hands, using water purifiers and disinfectants and taking rehydration salts for diarrhoea.
But the aid community is not devoting sufficient funds or attention to the problem, the reports say.
The Kenyan government is working with aid groups to educate the public on good hygiene, improve water chlorination and provide communities with water purifiers and disinfectants. But the financial burden is high, says Kenya's Health Minister Shahnaaz Sharif.
"A lot of donor agencies are not concentrating on diarrhoea and then it is left up to the individual governments to handle those programmes and most governments cannot cope," Sharif told AlertNet.
The Kibera health worker said she believed some funding for HIV, TB and malaria would do more good if it was diverted to treating diarrhoeal diseases in young children.
"If I was offered a wish list, I would say we channel a lot of funds (to) healthcare for children under five with an emphasis on diarrhoea and malnutrition," she added.
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