the one filed by the idjh, in that it alleged that liability had been accepted by the u.n. the 1990s. the lawyer stated that immunity: "should not be a shield to hide behind because the united nations (or the u.s. government) doesn't like the price tag that comes with the u.n.'s indisputable gross negligence in this case." this case, too, was dismissed by the u.s. district court, and the court of appeals. the appeal is currently before the united states supreme court. in december 2016, the then un secretary-general ban ki-moon finally apologized on behalf of un, saying he was "profoundly sorry" for the outbreak. the secretary-general promised to spend $400 million to aid the victims and to improve the nation's crumbling sanitation and water systems. as of march 2017, the un has come through with only 2 percent of that amount. morbidity and mortality domestic on 21 october 2010, the haitian ministry of public health and population (mspp) confirmed the first case of cholera in haiti in over a century. the outbreak began in the rural center department of haiti, about 100 kilometres (62 mi) north of the capital, port-au-prince. by the first 10 weeks of the epidemic, cholera spread to all of haiti's 10 departments or provinces. it had killed 4,672 people by march 2011 and hospitalized thousands more. the outbreak in haiti was the most severe in recent history prior to 2010; the world health organization reported that from 2010 to 2011, the outbreak in haiti accounted for 57% of all cases and 45% of all deaths from cholera worldwide. by january 2013, more than 6% of haitians acquired the disease. the highest incidence of cholera occurred in 2011 immediately following the introduction of the primary exposure. the rate of incidence slowly declined thereafter, with spikes resulting from rainy seasons and hurricanes. as reported by the haitian health ministry, as of august 2012, the outbreak had caused 586,625 cholera cases and 7,490 deaths. according to the pan american health organization, as of 21 november 2013, there had been 689,448 cholera cases in haiti, leading to 8,448 deaths. while there had been an apparent lull in cases in 2014, by august 2015 the rainy season brought a spike in the number of cases. at that time more than 700,000 haitians had become ill with the disease and the death toll had climbed to 9,000. as of march 2017, around 7% of haiti's population (around 800,665 people) have been affected with cholera, and 9,480 haitians have died. latest epidemiological report by who in 2018 indicate a total of 812,586 cases of cholera in haiti since october 2010, resulting in 9,606 deaths. however, a 2011 serological survey indicated that a large number of patients may have not been diagnosed: while only 18% of over a 2,500 respondents in a rural commune reported a cholera diagnosis, 64% had antibodies against it. international the first case of cholera was reported in the dominican republic in mid-november 2010, following the pan-america health organization's prediction. by january 2011, the dominican republic had reported 244 cases of cholera. the first man to die of it there died in the province of altagracia on 23 january 2011. the dominican republic was particularly vulnerable to exposure of cholera due to sharing a border with haiti, and a large haitian refugee population displaced following the 2010 earthquake. as of the latest epidemiological report by who in 2018, there has been a total of 33,188 cases of cholera in the dominican republic resulting in 504 deaths. in late january 2011, more than 20 venezuelans were reported to have been taken to hospital after contracting cholera after visiting the dominican republic. 37 cases were reported in total. contaminated food was blamed for the spread of the disease. venezuelan health minister eugenia sader gave a news conference which was broadcast on vtv during which she described all 37 people as "doing well". the minister had previously observed that the last time cholera was recorded in venezuela was twenty years before this, in 1991. in late june 2012, cuba confirmed three deaths and 53 cases of cholera in manzanillo; in 2013 there were 51 cases of cholera reported in havana. vaccination of half the population was urged by the university of florida to stem the epidemic. vulnerabilities infrastructure before the outbreak, haiti suffered from relatively poor public health and sanitation infrastructure. in 2002, haiti was ranked 147th out of 147 countries for water security. as of 2008, 37% of haiti's population lacked access to adequate drinking water, and 83% lacked improved sanitation facilities. as such, families often obtain their water from natural sources, such as rivers, that may be contaminated with v. cholerae. poor sanitation infrastructure allows cholera bacterium to enter these waterways. persons are subsequently infected via the fecal-oral route when the water is used for drinking and cooking, and poor hygiene often contributes to the spread of cholera through the household or community. there is also a chronic shortage of health care personnel, and hospitals lack adequate resources to treat those infected with cholera- a situation that became readily apparent after january 2010 earthquake. insufficient water and sanitation infrastructure, coupled with a massive earthquake in 2010, made haiti particularly vulnerable to an outbreak of waterborne disease. physiological malnutrition of the population, another pre-existing condition that was exacerbated by the earthquake, may have also contributed to the severity of the outbreak. research from previous outbreaks shows that duration of diarrhea can be prolonged by up to 70% in individuals suffering from severe malnutrition. furthermore, haitians had no biological immunity to the strain of cholera introduced since they had no previous exposure to it. therefore, physiological factors including malnutrition and lack of immunity may have allowed cholera to spread rapidly throughout the country. information lack of information and limited access to some rural areas can also be a barrier to care. some aid agencies have reported that mortality and morbidity tolls may be higher than the official figures because the government does not track deaths in rural areas where people never reached a hospital or emergency treatment center. limitations in the data from haiti stem from a lack of pre-outbreak lack of surveillance infrastructure and laboratories to properly test samples and diagnose cases. haiti was tasked with developing surveillance systems and laboratories after the 2010 earthquake and cholera outbreak which caused difficulties tracking the progression and scale of the outbreak. because of the lack of established surveillance, much of the case report data is anecdotal and potentially underestimated. also, because of lack of laboratory confirmation for the vast majority of cases of cholera, it is possible that other diarrheal diseases were being falsely classified as cholera. environmental rainy seasons and hurricanes continue to cause a temporary spike in incident cases and deaths. moreover, as a result of global warming and climate change, haiti is at an increased risk of cholera transmission. the intergovernmental panel on climate change (ipcc) advances that global warming between 1.5–2 degrees celsius will very likely lead to an increase in frequency and intensity of natural disasters and extreme weather events. resource-poor countries are poised to be affected more so than more developed and economically secure countries. environmental factors such as temperature increases, severe weather events, and natural disasters have a two-fold impact on the transmission potential of cholera in haiti: 1) they present conditions favorable to the persistence and growth of v. cholerae in the environment, and 2) they devastate a country's infrastructure and strain public health and health care resources. an exhaustive study into environmental factors influencing the spread of cholera in haiti cites above average air temperatures following the earthquake, "anomalously high rainfall" from september to october 2010, and damage to the limited water and sanitation infrastructure as likely converging to create conditions favorable to a cholera outbreak. challenges and solutions to eradication hundreds of thousands of dollars have been dedicated towards eradicating cholera in haiti since its introduction in 2010, yet unsanitary conditions and climate-driven forces allow cholera transmission to continue. while the number of new cases of cholera has drastically decreased from 2010, and is currently the lowest it has been since the outbreak began, the incidence remains at 25.5 per 100,000 population as of october 2018. over time, there has been significant progress in the reduction of caseloads and overall number of deaths. according to one paho/who report, "the cumulative case-fatality rate (cfr) has remained around 1% since 2011". these achievements can be contributed to intensified international and local medical efforts and an increased emphasis on preventative measures, including improved sanitation, such as latrines, and changes in haitian behaviors such as treating water, thoroughly cooking food, and rigorous hand-washing. despite these progresses, cholera remains endemic in haiti, and further resources are needed to fully eradicate it. after former un secretary general ban ki moon accepted un responsibility for the introduction of cholera in haiti in december 2016, moon projected a necessary $400 million in funding over two years in order to fully eradicate cholera in haiti. the government of haiti has dedicated itself to the complete eradication of cholera from haiti by 2022 as presented in the cholera elimination plan (pnec) 2013 – 2022. un secretary-general antónio guterres, successor to ban ki-moon, took up ban's commitment to assist haiti in the eradication of cholera when he took office on 31 december 2016, as demonstrated by strategic objective 2 of the 2017– 2018 haiti revised humanitarian plan. strategic objective 2 reads, "save lives from epidemics – reduce mortality and morbidity due to cholera outbreaks and other waterborne diseases through the reduction of vulnerability, strengthening of epidemiological surveillance and ensuring of rapid and effective response". the 2017 – 2018 haiti revised humanitarian plan identifies 1.9 million people in need of assistance for the protection from cholera, of which, 1.5 million people are targeted through programming totaling us$21.7 million. currently, the un and government of haiti are on target to reach the 2016 – 2018 midterm goal to reduce the incidence of cholera to less than 0.1% by the end of 2018. however, any disruption in funding of support services may result in a spike in transmission and the interruption of the downward trend. protracted crises: hurricane matthew 2016 the first challenge to the eradication of cholera in haiti is the country's vulnerability to disasters, putting it in a state of protracted crises. the climax of cholera incidence in haiti was in 2011 with 352,000 new cases following the introduction of cholera in haiti in late 2010. incidence rates gradually declined until 2016 when there was another spike in the transmission and incidence of cholera following hurricane matthew's destruction in haiti from 2–5 october 2016. there was a rise in cholera incidence from 32,000 new cases in 2015 to 42,000 new cases in 2016. by re-damaging haiti's fragile water and sanitation infrastructure, hurricane matthew allowed cholera to rear its head. these figures demonstrate that the fight against cholera in haiti, while improving, is on unstable ground. this indicates that while eradication efforts have largely been focused on vaccination and community education to prevent transmission, and oral rehydration to reduce mortality, the underlying vulnerabilities that perpetuate the disaster remain, particularly insufficient and unequal access to improved water and sanitation. funding while the government of haiti's cholera elimination plan (pnec) 2013 – 2022 and the new un system approach on cholera in haiti (see solutions below for more information) lay out plans for the elimination of cholera in haiti by 2022, these are entirely dependent on funding. in former secretary general moon's 5 december 2016 remarks he says, "without political will and financial support from the membership of the united nations, we have only good intentions and words. words are powerful – but they cannot replace action and material support". due to the infectious nature of cholera, any lapse in funding for programming will likely result in setbacks in elimination. as of 2017, funding for cholera is at risk due to increasing food insecurity and shelter needs for haitian refugees returning from the dominican republic. in the 2017 – 2018 revised haiti humanitarian plan, funding requirements for cholera programming is the third largest at $21.7 million, behind $76.6 million for food security and $103.8 million for shelter/nfi needs. vaccination campaigns in 2013, the government of haiti