When various nations around the world committed the equivalent of hundreds of millions of euros earlier this year to help Haiti recover from January's devastating earthquake, all of them stressed that rebuilding would take time.

And if anyone was under the illusion that progress would come quickly, they received a wake-up call last week when cholera - a disease virtually unknown in Haiti for decades - broke out in the remote Artibonite region.

More than 3,000 people contracted the disease and more than 250 people have died from it so far since the first case was recorded last week, causing some to cast a critical eye on the effectiveness of relief efforts in Haiti.

In an article for Germany's weekly Die Zeit newspaper, journalist Sven Stockrahm questioned why, 10 months on from the earthquake, Haitian authorities and the international community had been unable to ensure fresh drinking water and proper sanitation in the north of the country.

"Huge sums in aid money have gone there, but the people in the North seem to have been left to their own devices," Stockrahm told Deutsche Welle. "That seems pretty astonishing."

Stockrahm stresses that his critical remarks are not at all aimed at humanitarian aid workers, who by all accounts are doing vital work under very trying circumstances. The key question is whether a better coordination of the resources in place could have prevented cholera from occurring in the first place.

But clear answers are difficult to come by where Haiti is concerned.

Preventable or not?

The causes of cholera, lack of clean drinking water and poor sanitation, are well-known, but at present, no one is sure exactly how the disease even broke out in Artibonite. According to one speculation, the cholera bacteria may have been unwittingly introduced by aid workers themselves, but that is a mere rumor.

What is certain is that conditions in Haiti even before the earthquake were far from adequate. A study by the World Health Organization and UNICEF found that open defecation was prevalent among just under half of rural Haitians and that 3.7 million of Haiti's total population of 9 million had no reliable source of clean drinking water. Moreover, from 1990 to 2008, conditions deteriorated.

A similar study by the United Nations in 2009 determined that 42 percent of Haitians were not using an "improved water source." Haiti ranks dead last among countries in South America and the Caribbean in all major water and hygiene categories.

"Cholera is a sickness of poverty that is common in refugee camps where there’s not enough drinking water," Ernst Diekmann - a doctor with Germany's Society for Technical Cooperation, or GTZ - told Deutsche Welle. "Haiti was already an underprivileged country, and the situation was exacerbated by the natural catastrophe."

And as of September, there are still more than a million Haitians refugees from the earthquake.

"The disease broke out in camps populated by refugees, that is to say: people who fled the earthquake to safe regions and who live there under primitive conditions," Joost Butenop, a medical adviser to the aid organization Caritas, told Deutsche Welle. "Aid organizations have concentrated on the region specifically affected [by the earthquake] and haven't been following the refugees to any great extent."

Organizational challenges

Nonetheless, aid workers acknowledge that pre-existing deficiencies and the slow recovery process are two parts of the same overall problem that encouraged the cholera outbreak.

"The dramatic thing about Haiti is that even before the earthquake the health infrastructure was fully inadequate," Butenop said. "What was there was then destroyed, and reconstruction is proceeding very sluggishly. In that sense, there is always a greater danger of seeing the things we are now."

Earlier this year, the humanitarian organization Refugees International went even further, claiming that recovery efforts in Haiti were not just sluggish, but "paralyzed." Off the record, many people who work in the aid and assistance sector say that shortcomings in coordination often prevent help from getting where it's needed - or problems from being effectively anticipated.

That task falls to the United Nations and the Haitian government, and representatives of the former have openly admitted that the situation in Haiti tests their limits.

"We have one of the largest-scale humanitarian operations in the world running now ... and just keeping that show on the road is a huge job," Imogen Wall, a spokeswoman for the UN's Office for the Co-Ordination of Humanitarian Affairs, told Al Jazeera in response to the statement by Refugees International.

The will to help is there. Germany's Ministry for Economic Cooperation and Development, for instance, says that most of the 51.4 million euros ($72 million) it was allocated for Haiti has already been distributed or earmarked for future projects.

Yet merely distinguishing between emergency needs and long-term developmental requirements, and figuring out which government ministry is responsible, can be a complicated process. And coordinating the enormous number of private and public organizations trying to help in Haiti represents an organizational task of the highest order.

At this point, no one can say definitively whether any particular authority should have foreseen the danger of cholera in Haiti and taken precautionary steps to prevent it. But the outbreak of the disease in a country that has been the focus of so much international assistance suggests that overall organization and coordination remain problems that hinder aid initiatives from having their maximum possible effect.

Author: Jefferson Chase
Editor: Rob Mudge