Staggering debt obligations hampered Haiti's ability to provide basic sanitation and public health interventions to its population. According to the United Nations Development Program (UNDP) Human Development Report, Haiti ranks 145th out of 169 countries. 7 It has occupied the unenviable position of poorest nation in the Western Hemisphere for decades. Income per capita is US $560, 54% of Haitians live on less than US $1 a day, and 78% live on less than US $2 a day. In 2005, total external debt owed was US $1.5 billion, more than one-quarter of total GDP, 8 whereas Haiti spent only 1.2% of GDP on health care. 7 Widespread lack of access to clean water has been a chronic threat to the health of the Haitian population. 9 In 2007, only 63% had access to an improved water source, and only 17% had access to sanitation. 10 The earthquake on January 12, 2010 (which killed an estimated 250,000 people and displaced more than one-tenth of the Haitian population) turned the water situation in Haiti from bad to worse. It was in the context of hundreds of thousands of people living in refugee camps (1 million on the outskirts of Port-au-Prince alone) with intermittent access to drinking water and gross underprovision of sanitation facilities that cholera took hold. 11 Recent findings published in the New England Journal of Medicine and using third-generation single-molecule real-time DNA sequencing found that the clonal strain causing the Haiti outbreak was genetically similar to those previously isolated in Bangladesh. The study investigators concluded that, "Collectively, our data strongly suggest that the Haitian epidemic began with introduction of a V. cholerae strain into Haiti by human activity from a distant geographic source." 12 These results corroborated those from the CDC and the National Public Health Laboratory (NPHL) in Haiti. 13 The initial CDC findings were released in early November and sparked protests against the Nepali UN peacekeepers quartered near the river presumed to be the source of the outbreak. At least 3 Haitians were killed. 14 After a 100-year hiatus, Poverty, Global Health, and Infectious Disease cholera has now gripped Haiti and has started to spread to the Dominican Republic. 15 Given the increased virulence associated with this particular strain (the death rate in Haiti is 12 times higher than that of the 1991 Peruvian epidemic) there are calls from public health leaders to mass vaccinate the populations of the island and its closest neighbors. 16 Taking into account the long view of Haiti's history, from slavery to colonialism, debt, despotic leaders, and a woeful undersupply of public goods, the cholera outbreak seems less like an unforeseen catastrophe and more like an event that Virchow would have easily predicted.