Clean water is essential to preventing the return of cholera

In the Village de l'Espoir in northern Haiti's Kimbe district, a water pump is sealed with a heavy padlock. Twice a day, the elders provide access to the scarce resource, charging for each bottle of clean water 50 gourdes to cover purification costs.

An alternative free supply of clean water is more than an hour's walk away, so many local people instead drink from a dirty local river or use water from an infected well, supposedly reserved for agricultural irrigation.

Nearby, local government staff supported by Oxfam and Unicef are dealing with the consequences. Wearing black T-shirts with the slogan in Creole "Cholera, it's not finished", they discuss hygiene and co-ordinate chlorine spraying in the area, two days after a villager contracted the disease.

Nearly five years after cholera was first identified in Haiti, it remains endemic.

"We are trying to decide whether to step up staffing to prepare for a fresh outbreak," says Oliver Schulz, head of mission for Medecins Sans Frontieres, citing an increase in cases last year and the arrival of the rainy season in May.

He is standing in a makeshift cholera treatment centre in Dikini, one of several the charity runs in Port-au-Prince. Behind him, a woman vomits violently into a bucket, while four others lie on specially adapted beds.

There was an increase to at least 5,500 infections last year - a figure some believe may be an underestimate, given limited surveillance and a desire by some officials to downplay the impact. The cases are often recorded as "acute diarrhoea".

Not far outside the Haitian capital, international donors have recently provided funding for an Ebola isolation area, in case the disease spreads from Africa. But Mr Schulz is more concerned about the unwillingness of donors or the government to take over staffing for the far more pressing concern of cholera.

The country has long had severe health problems, but cholera was not one of them until October 2010. In the space of a few weeks, more than 700,000 infections were recorded and at least 8,800 people died. Tens of thousands more have suffered since, causing personal loss, economic hardship and a drain on medical staff.

There seems little doubt about the origin of the outbreak. DNA analysis has shown the cholera strain is almost identical to one widespread in Nepal, which had sent 1,000 unscreened soldiers as part of the UN Minustah peacekeeping mission in Haiti.

The outbreak was traced to a military camp for the soldiers in Meille, where leaking sewage pipes spread the infection into the Artibonite river, widely used for drinking and washing.

"How can the UN defend human rights if it doesn't respect them itself?" asks Mario Joseph, managing attorney of the Bureau des Avocats Internationaux in Haiti.

He has launched compensation claims for families whose members have died from cholera and others who lost jobs and had to withdraw children from school.

Since 2013, Mr Joseph and others have pursued actions - so far fruitless - in the US, the location of the UN headquarters and the domicile of several Haitian families affected. The UN, via the US, has pleaded immunity.

Sandra Honore, the UN secretary-general's special representative in Haiti, says: "It's not our practice to comment on matters under litigation . . . The UN has been supporting the government of Haiti ever since the outbreak. Cholera remains a threat and it is important to address the risk factors."

For now, it is clear that more needs to be done to prepare for the next outbreak. Greater investment will be required to provide clean water and improved sanitation to prevent its return.

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