The Unintended
Health
Consequences of
Globalization
Italo Subbarao DO,MBA
Director Public Health Readiness Office
Deputy Editor Journal of Disaster Medicine
Center 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 Energy
Deforestation
↑Consumption
Greenhouse Gases
Climate Change
↑Natural Disasters
Urbanization
Overpopulation
Denser Populations
↑Risk Infectious DZ
↑Risk of Pandemic
Trade and
Commerce
Lenient barriers to
production.
Lassiez-Faire
Defective Products
Toothpaste, 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 Dioxide
10000 years before 2005
Methane
10000 years before 2005
Nitrous Oxide
10000 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
Planning
Mitigation
DISASTER
Rehabilitation
Response
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
http://www.em-dat.net/
Continental Comparisons
http://www.em-dat.net/
Mortality and Population Affected
http://www.em-dat.net/
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 immunization
NA 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 Consequences
Name
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 syndrome
From Wikipedia, the free encyclopedia
http://en.wikipedia.org/wiki/SARS
Greatest Growth: Asia/Pacific and
Latin America
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
Resourcesdiscussed now with appropriate
legal staff.
• Human
•Supply
Overwhelming
Patient
Load
Transport
Consider
stockpiling of essential
Challenges
materials and contact contingency
• Care for Non-Infectious
vendors Patients ie.
CVA, MI
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 AlQaeda “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 Domains
1.0 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 Matrix
Competency
Domains
1.0 Preparation and
Planning
Core
Competencies
Health System Level of Proficiency
Informed
Worker/Student
Practitioner
Leader
1.1 Demonstrate
proficiency in the use
of an all-hazards
framework for disaster
planning.
1.1.1 Describe the allhazards 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 healthrelated 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 healthrelated needs of all
ages and
populations in
community and
institutional disaster
plans.
TARGET GROUP: HOSPITAL ADMINISTRATOR
Core Competencies
Expected Level of Disaster Education and Training
Informed
Worker/Student
Practitioner
Leader
1.0 Demonstrate proficiency in the use of an all-hazards
framework for disaster planning and response.
X
1.2 Demonstrate proficiency in addressing the health-related
needs, values, and perspectives of all ages and populations in
community and institutional disaster plans.
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.
For
X
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: LABORATORY TECHNOLOGIST
Core Competencies
Expected Level of Disaster Education and Training
Informed
Worker/Student
1.1 Demonstrate proficiency in the use of an all-hazards
framework for disaster planning.
Practitioner
X
1.2 Demonstrate proficiency in addressing the health-related
needs, values, and perspectives of all ages and populations in
community and institutional disaster plans.
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.
For
Leader
X
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.
Geo-Climatic
1,000
Bio
100
Chem
10
N/R
MD/DO
RN
Para
B
T
R
Time
Competencies
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