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 Di

Document Sample
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 Di Powered By Docstoc
					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 Rapid Industrialization Urbanization Developing Country Need for Energy Deforestation ↑Consumption Overpopulation Unintended Consequences Greenhouse Gases Climate Change ↑Natural Disasters Denser Populations ↑Risk Infectious DZ ↑Risk of Pandemic

Trade and Commerce

Lenient barriers to production. Lassiez-Faire
Sharing of Ideologies

Defective Products Toothpaste, Toys ↑Risk of Toxic Expo ↑Risk of Pandemic
↑Risk of Global Terrorism

Communication

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 Spanish Asian Hong Kong Date 1918-1920 1957-1958 1968-1969 Deaths 40 million 1-1.5 million .75-1 million Subtype H1N1 H2N2 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 Human Resources

Solutions 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 Pre-Identify adequate Alternative Care Sites and Staff Considerations. Screen all patients outside Emergency Department. EMS education. Community Education.

Overwhelming Patient Load

Care for Non-Infectious Patient ie. CVA, MI

• Human •Supply Transport Overwhelming Patient Load of essential Consider stockpiling Challenges materials and contact contingency • Care for Non-Infectious Patients ie. vendors CVA, MI

Ethics Ventilator Triage

Have ventilator triage plans discussed now with appropriate Resources legal staff.

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 Core Competencies Health System Level of Proficiency Informed Worker/Student
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 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.

Practitioner
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. 1.2.2 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.

Leader
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

1.2.3 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 1.0 Demonstrate proficiency in the use of an all-hazards framework for disaster planning and response. 1.2 Demonstrate proficiency in addressing the health-related needs, values, and perspectives of all ages and populations in community and institutional disaster plans. 2.1 Demonstrate proficiency in the detection of and immediate response to a disaster or public health emergency. 2.2 Demonstrate proficiency in the use of information and communication systems in a disaster. 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. 3.1 Demonstrate proficiency in the activation of national, regional, state, local, and institutional incident command and emergency operations systems. 3.2 Demonstrate proficiency in the mobilization and coordination of disaster support services. 3.3 Demonstrate proficiency in the provision of health system surge capacity for the management of mass casualties in a disaster. 4.1 Demonstrate proficiency in the prevention and mitigation of health, safety, and security risks to yourself and others in a disaster. 4.2 Demonstrate proficiency in the use of personal protective equipment at a disaster scene or receiving facility.
For

Practitioner

Leader X

X

X

X

X

X

X

X

X

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. 1.2 Demonstrate proficiency in addressing the health-related needs, values, and perspectives of all ages and populations in community and institutional disaster plans. 2.1 Demonstrate proficiency in the detection of and immediate response to a disaster or public health emergency. 2.2 Demonstrate proficiency in the use of information and communication systems in a disaster. 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. 3.1 Demonstrate proficiency in the activation of national, regional, state, local, and institutional incident command and emergency operations systems. 3.2 Demonstrate proficiency in the mobilization and coordination of disaster support services. 3.3 Demonstrate proficiency in the provision of health system surge capacity for the management of mass casualties in a disaster. 4.1 Demonstrate proficiency in the prevention and mitigation of health, safety, and security risks to yourself and others in a disaster. 4.2 Demonstrate proficiency in the use of personal protective equipment at a disaster scene or receiving facility.
For

Practitioner

Leader

X

X

X

X

X

X

X

X

X

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
10

Chem
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 Yellow Green 6 10 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