PORT-AU-PRINCE, Haiti – The cholera outbreak that struck Haiti is a sobering reminder of the tasks the country faces as it prepares for November’s presidential election.

While newscasters talk about reconstruction, the grim truth is that much of what Haiti needs – decent housing, water, sanitation, health care, education and economic opportunities – did not exist even before the Jan. 12 earthquake.

Rural areas are even more neglected than Port-au-Prince, the crowded and gridlocked capital that has been the focus of international attention since the quake.

Recovery will mean not just clearing rubble and rebuilding houses, but building infrastructure, improving health care and education and investing in economic development in rural communities so farmers can stay in the countryside instead of migrating to Port-au-Prince’s slums and tent camps.

January’s tragedy was a “disaster sitting on a much greater disaster, which is the structural disaster of dysfunction and grinding poverty for decades and decades,” said Scott Campbell, country director for Catholic Relief Services, the U.S. bishops’ relief and development agency.

About half of Haiti’s 10 million people live on less than a dollar a day; another quarter live on twice that amount. Half the population is under age 24, but most people have completed only primary school. University graduates often leave for better opportunities abroad, making it difficult to attract talented workers to government jobs and exacerbating slow or inept public administration.

People have become Haiti’s biggest export. A March report by the Rand Corp. found that nearly one-third of Haitian households – 44 percent in cities – receive money from relatives working abroad. In 2008, those remittances were more than twice the country’s earnings from export products.

While the economies of most of the hemisphere’s developing countries have grown in the past decade, Haiti’s has shrunk by more than a third since the 1960s. Many of its social and economic indicators are closer to those of sub-Saharan African countries than to their Caribbean or Latin American neighbors.

Part of the reason is historical. The successful slave revolt that led to independence in 1804 was met with indifference by most of that era’s world powers. More recently, three decades of strong-arm rule by Francois and Jean-Claude Duvalier centralized power in Port-au-Prince, neglecting the countryside.

In the 1980s and 1990s, international lenders urged Haiti to shift from agriculture – the mainstay of more than half its citizens – to export manufacturing. People flocked to cities in search of jobs. Port-au-Prince, which was built for about 300,000 residents, grew to 3 million.

Even before the earthquake, about one-third of the capital’s residents lacked access to water, and half had no latrines or sanitation services. Overcrowding in unsafe housing contributed to the earthquake death toll, estimated at between 230,000 and 300,000.

Meanwhile, Haiti began importing food more cheaply than Haitian farmers could produce it. The move further impoverished rural dwellers, who saw their markets shrink. A study released in October by Oxfam America found that food aid flooding into the country since the earthquake has further skewed markets, making it even harder for farmers to sell their products. Oxfam recommended that aid agencies buy food locally when possible instead of importing food.

In the 1990s, the United States and other countries offered or withdrew economic assistance depending on Haiti’s political stability. As a result, development plans were only partly funded. The Rand Corp. study also found that many of those plans were poorly designed and did not respond to an overarching strategy.

In the wake of the earthquake, the lack of an overall plan remains a danger.

“I don’t think the government has an easy task,” Campbell said. “No government would, in this situation. It is very complex. But the government has been slow in putting out some kind of direction and strategy, and that has made the efforts more difficult.”

Some critics also blame aid agencies for foot-dragging. Most large agencies have spent only about 10 percent of the funds they collected after the earthquake. Campbell, however, said that 10 percent is about right for earthquake relief. Providing tents, water, emergency rations and latrines is not expensive, he said. The most expensive work – rebuilding and development – will follow, but depends on government planning and direction.

Entrenched corruption further complicates the problem. In a new survey of perceptions of corruption, conducted by Transparency International, Haiti ties with Libya and Iran, ranking 146th out of 178 countries.

It is not clear whether the billions of dollars in aid pledged by foreign donors will be more effective than responses to other natural disasters that have battered Haiti.

Food aid and other assistance began pouring into Haiti in the 1950s in response to a humanitarian crisis caused by hurricanes, explained Robert Maguire, associate professor of international affairs at Trinity Washington University. Many of the aid agencies that began working then have remained in Haiti.

Aid organizations “celebrate their 40th or 50th anniversary in a country,” Maguire said in a telephone interview with Catholic News Service. “That is just bizarre. What are you celebrating?”

The situation creates a vicious circle: Donors trust nongovernmental agencies more than the government to handle funds, but that can give the agencies more power than the government. Skilled Haitians also are drawn to development agencies, which offer better salaries and the equipment they need to do their jobs well.

Since the earthquake it has been “very fashionable to damn the Haitian government for not doing anything, but that’s the result of a long process in Haiti of supporting NGOs and bypassing government, for better or worse,” Maguire said.

Both donors and Haitian officials now realize that the government needs support, he said, but it remains to be seen whether countries will provide funds “to empower the government of Haiti so it can regulate, set the agenda and somehow have authority over the NGOs.”

Maguire worries that the nearly 10-month lag in reconstruction planning has already missed a key opportunity. In January, many earthquake victims fled the capital to take refuge with relatives in rural areas.

“I was advocating very strongly (for the government to) move quickly and accommodate these people, provide welcome centers,” so they could have a livelihood in the countryside instead of returning to the city, he said. “None of that happened. Instead, all the attention has been on Port-au-Prince.”

Now most of those people are returning to the capital, and some are bringing relatives to take advantage of the food, water and health services available in some of the larger tent camps.

“With this as the trend, I’m beginning to have severe doubts that Haiti will be built back better,” Maguire said.

The tasks ahead – rural development, providing social services, improving public administration – are daunting, especially with nearly 20 candidates vying for the presidency in the Nov. 28 elections. Campaign season is slowing the emergency response as government officials resign to run for office and other countries wait to see who will be elected.

Bishop Pierre-Andre Dumas of Anse-a-Veau and Miragoane leads Caritas Haiti, the church’s aid and development agency. He said he worries that between local troubles and other international crises, Haiti could get lost.

“The greatest danger is that with so many problems in the world – with the ongoing financial crisis and other problems – Haiti may become, once again, a forgotten emergency,” the bishop said. “We must avoid that.”