The Unintended Health Consequences of Globalization Italo Subbarao DO,MBA Director Public Health...

The Unintended Health Consequences of Globalization

Italo Subbarao DO,MBADirector Public Health Readiness Office

Deputy Editor Journal of Disaster MedicineCenter for Public Health Preparedness

& Disaster Response

Why???...Ok What is Globalization• Globalization "is the closer integration of

the countries and peoples of the world ...brought about by the enormous reduction of costs of transportation and communication, and the breaking down of artificial barriers to the flows of goods, services, capital, knowledge, and people across borders.”

Joseph Stiglitz Noble Prize Economist

Globalization: The Flattening of the World• Global Economy

• Dramatic Increases in Technological Efficiencies: Cheaper Goods and Services

• Outsourcing: Radiologist doing evaluations from Australia

• Increased Trade and Commerce

• Communication • Virtual Communities (Shared Ideologies)• 24/7 News world

Globalization: Closing the Economic Gap between Developing and Developed Nations

The Rise of Asia in the Global Economy

Globalization’s Impact on Developing Countries…Too good to be true!!

• Rapid Industrialization and Urbanization• Demand for Energy and Land• Profits maximized: No focus on standards

and regulations • Demand for all populations to be involved in

the “gold rush”

I thought globalization is good right???

Globalization Developing Country

Unintended Consequences

Rapid Industrialization

Need for EnergyDeforestation↑Consumption

Greenhouse GasesClimate Change↑Natural Disasters

Urbanization Overpopulation Denser Populations↑Risk Infectious DZ↑Risk of Pandemic

Trade and Commerce

Lenient barriers to production.Lassiez-Faire

Defective ProductsToothpaste, Toys↑Risk of Toxic Expo↑Risk of Pandemic

Communication Sharing of Ideologies

↑Risk of Global Terrorism

Goal: Unintended Consequences of Globalization • Review Global Trends in Natural

Disasters• Review the Health Impact of Climate

Change • Review the Concern of Pandemic

Influenza and Emerging Infections• Review the Risk of Global Terrorism

• Case Study of the Virginia Tech Tragedy

Climate System

Greenhouse Effect

Global Warming

Carbon Dioxide10000 years before 2005

Methane10000 years before 2005

Nitrous Oxide10000 years before 2005

Greenhouse Gases

• Carbon Dioxide 35% increase since industrial age • Combustion of Fossil Fuels• Deforestation

• Methane 154% increase since industrial age• Animal (cattle and sheep) gas

• Nitrous Oxide• Water Vapor

World Consumption

Climate Change Controversy

• Nobody argues that the earth is getting warmer and that climate change is occurring.

• Controversy is global warming part of the natural planetary cycle or does man have influence?

• Other issue is whether curbing CO2 emissions now will have a real impact in the immediate future.

Curbing Carbon Emissions: No Easy Solution

• Alternative Energy Non-Fossil Fuel Based• Wind, Solar, Nuclear• Ethanol Corn, Sugar Cane, Catalytic• Energy Efficiency

• Carbon Emission Regulation: Carbon Tax

Kyoto Protocol: UN Agreement

• Protocol signed by 167 countries: US and Australia notable exceptions• China and India have signed on

• Cut greenhouse gas emissions by 5% less than 1990 emissions.

• If unable can purchase carbon credits but are penalized in the future.

• Treaty expires 2013

Unintended Consequences of Climate Change

Defining a Disaster

Risk = Hazard * Vulnerability

Phases in Disaster Preparedness

Mitigation

Rehabilitation

Planning

Response

DISASTER

Societal Disruption

• Infrastructure destruction• Hospitals• Primary Health

Centers• Homes• Transportation

Criteria for a Natural Disaster

• 10 or more people reported killed • 100 people reported affected • Declaration of a state of emergency • Call for international assistance

• http://www.em-dat.net/

Natural Disasters

http://www.em-dat.net/

Comparative Review of Natural Disasters


Continental Comparisons


Mortality and Population Affected


Extreme Heat and Cold Waves: Populations susceptible• Elderly and Children• Those with Chronic Diseases• Lower Socioeconomic: Homeless

Climate Change???

Infectious Disease and Globalization:

• Urbanization (Developing Countries)• Overpopulation • Travel Projections• Climate Change Impact

Globalization and Urbanization:

• 2006 UN Report: 1976 1/3rd of the population lived in cities

• Today 50% of the worlds population lives in cities

• Greatest growth is in developing countries: China and India

Overpopulation: Feed Me!!!

• Pollution• Improper Waste Disposal• Depletion of Natural Resources• Overcrowding/ Slums: Mixing of Human

and Animal populations• Increased Consumption

Travel projections until 2017

Influenza A

• Orthomyxoviridae:• Single Stranded RNA Virus

• Two proteins responsible for virulence• Hemagglutinin (HA) (1-16)• Neuraminadase (NA) (1-9)

• Principal method of protection is seasonal immunizationNA inhibitors are also efficacious

Typical Seasonal Flu occurs during the winter season on average 36,000 deaths per year

Pandemic Influenza

• Antigenic Shift: Occurs from genomic mixing of distinct virus strains with human strains.• Avian, Swine, etc.

• New Strain of Influenza: • Humans will have no preexisting immunity

• Efficacy of Antivirals: Unknown• No Vaccine will be available• Avian Influenza is not yet a Human

Pandemic• Cannot Predict Level of Virulence

Historical ConsequencesName Date Deaths Subtype

Spanish 1918-1920 40 million H1N1

Asian 1957-1958 1-1.5 million H2N2

Hong Kong 1968-1969 .75-1 million H3N2

Overarching Objectives• Phase: Pre-Pandemic• Reduce opportunities for human infection• Strengthen Early Warning Systems• Phase: Emergence of a Pandemic• Contain or delay the spread at the source• Phase: Pandemic Declared and Spreading• Reduce morbidity, mortality, and social

disruption• Conduct Research to guide Response

SARS: Window to a Pandemic • Emerging Respiratory Infection in a Globalized

World• Travel and Commerce

• Communication Alerts

• High Mortality• High Secondary Infection Rate in Healthcare Workers

• No Vaccine• Unknown Response to Antivirals

SARS Implementation Strategies :

• Singapore: Patients with respiratory symptoms seen outside the Emergency Department

• Toronto: EMS personnel restricted transport of patients with respiratory symptoms.

• Once case definition present: High Index of Clinical Suspicion among Clinicians

• Worked in Allentown

Severe acute respiratory syndromeFrom Wikipedia, the free encyclopediahttp://en.wikipedia.org/wiki/SARS

Greatest Growth: Asia/Pacific and Latin America

• Human Resources• Overwhelming Patient Load• Care for Non-Infectious Patients ie. CVA, MI• Surge Capacity: Alternative Care Sites• Ethics: Ventilator Triage

Challenges Solutions

Human Resources Pre-identify critical support staff (both Inpatient and Outpatient) Seasonal Influenza Vaccine May Confer Immunity Strict Infection Control Measures with N-95 advanced training.Consider Antiviral Prophylaxis

Overwhelming Patient Load Pre-Identify adequate Alternative Care Sites and Staff Considerations.

Care for Non-Infectious Patient ie. CVA, MI

Screen all patients outside Emergency Department. EMS education. Community Education.

Ethics Ventilator Triage Have ventilator triage plans discussed now with appropriate legal staff.

Supply Transport Challenges

Consider stockpiling of essential materials and contact contingency vendors

Climate Change and Infectious Disease

Climate Change???

• Thursday, 14 March 2007, 19,577 recorded cases of dengue were reported. The national average incidence rate is 325.8 per 100,000 inhabitants (Source: Mercosur and MSPBS).

• The dengue outbreak is concentrated in the capital city of Asunción Capital (incidence rate = 1166.6 per 100,000), .

• Climate in the form of continuous rainfall has played a major role in this outbreak.

Supersize Me!!!

Global Terrorism: Influence of Globalization• Internet has become a significant

recruitment tool.• Enabled people with like minded

ideologies to have a virtual relationship.• Real threat is not only Al-Qaeda but Al-

Qaeda “Inspired” Groups.

• Terror strategies can be easily shared• Example Bomb building•

Global Terrorism: Are we preparing for the right threats? • Efforts have focused on CBRNE• Most likely threat: Suicide Bombing or

Improvised Explosive Device• Examples London, Madrid, Mumbai,

bombings.• Recent attempts in Glascow and London

underscore this persistent threat.

Globalization and its Impact on Health

• The world has become increasingly interconnected and interdependent

• This has positive and negative consequences.

• Every health system responder should be aware of the new health threats posed by globalization and take a leadership role to educate others in there health system.

Educational Framework for Disaster Medicine and Public Health Preparedness

Goals

• Create an educational framework that would meet the practical needs of all health system responders.

• Consistency and common lexicon among all learners and level of responders.

• Create a framework that would allow for scientific evaluation and assessment.

Methodology

• Systematic Review (Jan. 2004-July 2007) peer reviewed, and unpublished (ASPR, CDC,DHS)

• Convened an Expert Panel • Identified Commonality and Gaps:

Ethics, Law, Mortuary, Risk Communication, Mental Health, Cultural Competence, Leadership.

Competency Domains1.0 Preparation and Planning

2.0 Detection and Communication

3.0 Incident Management and Support Services

4.0 Safety and Security

5.0 Clinical/Public Health Assessment and Intervention

6.0 Contingency, Continuity, and Recovery

7.0 Public Health Law and Ethics

Health System Responder Level of Proficiency

Informed Worker/Student: Health system professionals and students who require understanding in a particular aspect of disaster planning, mitigation, response, or recovery. These persons should be able to describe core concepts or skills but may have limited ability to apply this knowledge.

Practitioner: Health system professionals who are required to apply clinical or public health knowledge, skills, and values in disaster planning, mitigation, response, and recovery.

Leader: Health system professionals with administrative decision-making roles or functions in disaster planning, mitigation, response, or recovery.

Learning MatrixCompetency Domains

Core Competencies

Health System Level of Proficiency

Informed Worker/Student

Practitioner Leader

1.0 Preparation and Planning

1.1 Demonstrate proficiency in the use of an all-hazards framework for disaster planning.

1.1.1 Describe the all-hazards framework for disaster planning.

1.1.2 Explain key components of your regional, community, institutional, and personal/family disaster plans.

1.1.3 Explain the motives, tactics, and reasons for terrorism in modern society.

1.1.4 Summarize your regional, community, office practice, and institutional disaster plans.

1.1.5 Explain the purpose of, and your role in, community and institutional disaster exercises and drills.

1.1.6 Conduct hazard vulnerability assessments for your office practice, community, or institution.

1.1.7 Create, evaluate, and revise disaster plans, exercises, and drills for your region, community, or institution to address identified disaster risks and vulnerabilities.

1.2 Demonstrate proficiency in addressing the health-related needs, values, and perspectives of all ages and populations in community and institutional disaster plans.

1.2.1 Identify individuals (of all ages) and populations with special needs who may be more vulnerable to adverse health effects in a disaster

1.2.2 Delineate medical and mental health issues that need to be addressed in community and institutional disaster plans to accommodate the needs, values, and perspectives of all ages and populations.

1.2.3 Create, evaluate, and revise policies and procedures for meeting the health-related needs of all ages and populations in community and institutional disaster plans.

For each competency and responder category, learning objectives must be developed to accommodate persons in the target group who perform at different levels and in varying degrees based on their educational level, experience, professional role, and job function in disaster planning, mitigation, response, and recovery.

TARGET GROUP: HOSPITAL ADMINISTRATOR

Core Competencies Expected Level of Disaster Education and Training


Practitioner Leader

1.0 Demonstrate proficiency in the use of an all-hazards framework for disaster planning and response.

X


X

2.1 Demonstrate proficiency in the detection of and immediate response to a disaster or public health emergency.

X

2.2 Demonstrate proficiency in the use of information and communication systems in a disaster.

X

2.3 Demonstrate proficiency in addressing cultural, ethnic, religious, linguistic, and special health-related needs of all ages and populations in community and institutional emergency communication systems.

X

3.1 Demonstrate proficiency in the activation of national, regional, state, local, and institutional incident command and emergency operations systems.

X

3.2 Demonstrate proficiency in the mobilization and coordination of disaster support services.

X

3.3 Demonstrate proficiency in the provision of health system surge capacity for the management of mass casualties in a disaster.

X

4.1 Demonstrate proficiency in the prevention and mitigation of health, safety, and security risks to yourself and others in a disaster.

X

4.2 Demonstrate proficiency in the use of personal protective equipment at a disaster scene or receiving facility.

X

TARGET GROUP: LABORATORY TECHNOLOGIST

Core Competencies Expected Level of Disaster Education and Training


Practitioner Leader

1.1 Demonstrate proficiency in the use of an all-hazards framework for disaster planning.

X


X

2.1 Demonstrate proficiency in the detection of and immediate response to a disaster or public health emergency.

X

2.2 Demonstrate proficiency in the use of information and communication systems in a disaster.

X

2.3 Demonstrate proficiency in addressing cultural, ethnic, religious, linguistic, and special health-related needs of all ages and populations in community and institutional emergency communication systems.

X

3.1 Demonstrate proficiency in the activation of national, regional, state, local, and institutional incident command and emergency operations systems.

X

3.2 Demonstrate proficiency in the mobilization and coordination of disaster support services.

X

3.3 Demonstrate proficiency in the provision of health system surge capacity for the management of mass casualties in a disaster.

X

4.1 Demonstrate proficiency in the prevention and mitigation of health, safety, and security risks to yourself and others in a disaster.

X

4.2 Demonstrate proficiency in the use of personal protective equipment at a disaster scene or receiving facility.

X

For each competency and responder category, learning objectives must be developed to accommodate persons in the target group who perform at different levels and in varying degrees based on their educational level, experience, professional role, and job function in disaster planning, mitigation, response, and recovery.

Competencies

BioChem

N/R10100

1,000

MD/DO

RN

Para

R

TB

Geo-Climatic

Time

Next Steps

• Development of Learning Objectives• Development of Evaluation Measures• Prospective Randomized/ Control

Educational Trial (web-based vs. didactic).

Bombings: Blast Injury

• Primary Blast Injury: • Overpressure Wave Impacts Hollow Viscous

and Air-filled Organs. • Examples: TM rupture, Blast Lung, Intestinal

perforation Cerebral Contusion???

• Secondary Blast Injury: • Most common type of injury.• Due to shrapnel or secondary foreign objects

that fly into victim

• Tertiary Blast Injury: • Victim thrown into stationary object

Triage: Sorting patients…sort of.

• MCI Triage• Breakdown into two categories• Urgent or Non-Urgent

• Triage should take place outside ED • Insufficient Evidence to support any

particular Triage Methodology START vs. MASS vs. Priorities

Injury Severity

• Open Air Bombing victims usually present at two extremes.• Either ISS less 5 or ISS greater than 15

• ISS greater than 15 considered critical and is associated with increased mortality.

• Critical Mortality: The number of patients who presented to the hospital with an ISS >15/ Total Number of with ISS of 15.

Critical Mortality Rates: Identifying Preventable Deaths• Buenos Aires 29%• Beirut 37%• NYC 38%• London 15%• Israel Confined Space 18%

• Immediate Mortality Confined 46%• Open Air 7%

• Average is usually around 20 %

Critical Mortality and Overtriage

• Landmark study: Direct Correlation• Dr. Eric Frykberg 2002• Greater Overtriage the Greater the Critical

Mortality

This is disputed

London only had a 35% overtriage rate

New York 70%

Beirut 80%

Madrid had 89%

Virginia Tech Case Study: You are a Level 3 Trauma Center• April 16th 2007 Campus of Virginia Tech• Mass Shooting: Multiple Victims• At least 30 Dead (33 found dead at the

scene including the shooter).• 26 Victims needed to be evaluated• Closest Level I Center was 45 miles

away.

Unable to Medevac

• Patients Distributed Equitably• Regional Response included 2 Level 3

Trauma Centers and 1 Non-Designated• 25 out of the 26 patients triaged in the

field• START Triage

Red 6

Yellow 10

Green 12

Triage broke down into two groups

Injury Severity• 12/26 patients with ISS> 9• 5 patients with ISS> 15• Avg. ISS of 8.2• Previous Israeli studies have

comparatively evaluated gunshot MCI from bombing MCI

• Gunshot MCI tend to have a moderate ISS score of 9 or greater

• In previous studies it has been accepted that one can eliminate those DOA

Critical Mortality

• 1 victim was DOA another victim died after arrival at the hospital.

• Critical Mortality Rate ???• 1/5 = 20%. • Trick question you could calculate either

way but…

Overtriage??? Not a Friend but is it a Foe?• Overtriage calculated• Number of Red and Yellow – Total no.

ISS > 15/ Total No. Red and Yellow• Overtriage was 69% • Recent modeling study also

demonstrated great variability with overtriage and its relationship to critical mortality.

Lessons Learned:Level I or not be ready!• Preventing Copycats?

• Mental Health screenings for those getting handguns

• Gun control measures

• Rural America is not Immune• Level I Trauma Centers should take a

proactive role in regional education

The Unintended Health Consequences of Globalization Italo Subbarao DO,MBA Director Public Health...

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