Publications

    Abdulrazzaq Al-Saiedi, Kevin Coughlin, Muslih Irwani, Waad Ibrahim Khalil, Phuong Pham, and Patrick Vinck. 6/2020. “الترجمة العربية (Arabic Version): "Never Forget: Views on Peace and Justice Within Conflict-Affected Communities in Northern Iraq"”.Abstract

    This survey offers a snapshot of the perceptions and attitudes about peace and justice within communities affected by the conflict with the Islamic State (IS). It is based on 5,213 interviews conducted in 2019 among a representative sample of internally displaced persons in northern Iraq and residents of the city of Mosul and surrounding areas.The research documents a severe lack of trust in official institutions, particularly in the Government of Iraq itself, stemming in large part from the belief that these institutions do not act in the best interest of the population. Few respondents had confidence in the Government of Iraq’s ability to investigate the crimes committed by the Islamic State fairly and accurately and to provide justice to survivors of the conflict.Despite the mistrust, respondents favor local justice and truth-seeking mechanisms. They view these efforts as necessary to build a durable peace, alongside measures to address the root causes of the rise of IS and longstanding divisions between the people of Iraq. However, rather than the challenge being diversity itself, the challenge is the Government of Iraq’s ability to promote and facilitate reconciliation and unity.Without an accountable government that is perceived to be legitimate and is trusted by all Iraqis, calls for justice and accountability may go unanswered, and the country risks slipping back into another conflict.

    The research was conducted by the Harvard Humanitarian Initiative in partnership with Mosul University and the Iraq-based Public Policy Institute. It was supported by the Ministry of Foreign Affairs of the Netherlands, which played no role in the design, analysis or publication of the research.

    Sarah Ferguson, Vincenzo Bollettino, Phuong Pham, Patrick Vinck, Rachel Dickinson, Alexis Smart, and Evan Bloom. 5/2020. “Bangladesh Network Analysis Report”.Abstract
    Coordination among actors during an emergency is crucial for effective, efficient action. The existence of pre-disaster relationships between actors can strengthen the speed with which coordination occurs in a disaster setting, making relationshipbuilding before a disaster an important element of preparedness. As such, understanding the relationships between stakeholders working to advance disaster resilience and response is a crucial first step to support institutional strengthening and capacity building. The Harvard Humanitarian Initiative (HHI), Concern Worldwide, and Jagrata Juba Shangha (JJS) are jointly implementing programs to enhance climate change adaptation and disaster resilience among coastal communities in Bagerhat District, Bangladesh. This district is located in Bangladesh’s low-elevation coastal zones, which are especially vulnerable to natural disasters and have already begun to see the effects of climate change. Bagerhat has high levels of food and water insecurity and poverty, and is highly vulnerable to natural disasters and climate change impacts (5). The district has been heavily impacted by recent cyclones, and is experiencing sea level rise and saltwater intrusion. This network analysis was undertaken to support strengthening coordination and collaboration among actors working on climate change adaptation and disaster resilience in Bagerhat.
    Krzysztof Goniewicz, Maciej Magiera, Dorota Rucińska, Witold Pawłowski, Frederick M. Burkle Jr., Attila J. Hertelendy, and Mariusz Goniewicz. 5/2020. “Geographic Information System Technology: Review of the Challenges for Its Establishment as a Major Asset for Disaster and Emergency Management in Poland.” Disaster Medicine and Public Health Preparedness.Abstract

    Technical and technological progress in the 21st century, especially emerging geographic information system (GIS) technology, offers new and unprecedented opportunities to counteract the impact of crisis situations and emergencies. Computerization and development of GIS enabled the digital visualization of space for interactive analysis of multiple data in the form of models or simulations. Additionally, computerization, which gives rise to a new quality of database management, requires continuous modernization of computer hardware and software. This study examines selected examples of the implications and impact of the GIS commonly used in Poland.

    Eric Weinstein, Luca Ragazzoni, Frederick M. Burkle Jr., Mea Allen, David Hogan, and Francesco Della Corte. 5/2020. “Delayed Primary and Specialty Care: The Coronavirus Disease-2019 Pandemic Second Wave.” Disaster Medicine and Public Health Preparedness.Abstract

    Time is of the essence to continue the pandemic disaster cycle with a comprehensive post-COVID-19 health care delivery system RECOVERY analysis, plan and operation at the local, regional and state level. The second wave of COVID-19 pandemic response are not the ripples of acute COVID-19 patient clusters that will persist until a vaccine strategy is designed and implemented to effect herd immunity. The COVID-19 second wave are the patients that have had their primary and specialty care delayed. This exponential wave of patients requires prompt health care delivery system planning and response.

    Vincenzo Bollettino and Sarah Ferguson. 5/2020. “Case Study: Academic/NGO Collaboration to Understand Climate Change and Disaster Resilience Implementation in Bagerhat District, Bangladesh”.Abstract
    This case study describes a research collaboration between an academic institution and non-governmental organizations (NGOs) designed to inform programs to strengthen coordination in Bangladesh. The case describes the rationale for conducting the study, the research process, and outcomes of the research. The objective of the case study is to support local or municipal governments, NGOs, students, or other program managers to consider how collaboration with academic institutions could enhance their programs, as well as how research such as a network analysis could be useful to inform their work. For those interested in conducting a network analysis, the case also provides resources and tools to support researchers and organizations to replicate the study in their program context.
    Frederick M. Burkle Jr. and Asha V. Devereaux. 5/2020. “50 States or 50 Countries: What Did We Miss and What Do We Do Now?” Prehospital and Disaster Medicine.Abstract

    There have been multiple inconsistencies in the manner the COVID-19 pandemic has been investigated and managed by countries. Population-based management (PBM) has been inconsistent, yet serves as a necessary first step in managing public health crises. Unfortunately, these have dominated the landscape within the United States and continue as of this writing. Political and economic influences have greatly influenced major public health management and control decisions. Responsibility for global public health crises and modeling for management are the responsibility of the World Health Organization (WHO) and the International Health Regulations Treaty (IHR). This review calls upon both to reassess their roles and responsibilities that must be markedly improved and better replicated world-wide in order to optimize the global public health protections and its PBM. 

    Nasim Sadat Hosseini Divkolaye, Javad Khalatbari, Marjan Faramarzi, Fariba Seighali, Shokoufeh Radfar, Ali ArabKhazaeli, and Frederick M. Burkle Jr. 5/2020. “Frequency and Factors Associated with Violence Against Female Sex Workers in Tehran, Iran.” Sexuality & Culture.Abstract

    Female Sex Workers are among those women who are significantly more vulnerable to violence. Apart from the human rights perspective, assessing the frequency of violence among sex workers is especially important because of its relation to the spread of HIV and other sexually-transmitted infections. This cross-sectional, observational study was conducted among 263 female sex workers in southern parts of Tehran and their suburban regions in 2017 where the population is considered more socially and economically vulnerable. To evaluate univariate analysis between sexual violence and physical violence as dependent variables and the assumed exposures as well as confounders, the models were built distinctly. The models included exposures of the questionnaire as independent variables. The exposure factors with a p value of less than 0.2 were moved into the multiple logistic regression models. The rates of sexual violence and physical violence were reported as 72.2% and 82.3% respectively. According to our results, sexual violence is associated with higher education, working in streets, drug usage, having the experience of forced unprotected sex and feeling of discrimination. Physical violence is associated with low education, drug usage and feeling of discrimination in multiple analyses. Addressing the violence against female sex workers is a complex multifactorial issue in Iran. It requires structural changes in some social, legal, economic and health infrastructure programs.

    Frederick M. Burkle Jr. 4/2020. “Political Intrusions into the International Health Regulations Treaty and Its Impact on Management of Rapidly Emerging Zoonotic Pandemics: What History Tells Us.” Prehospital and Disaster Medicine. Read PublicationAbstract
    For a large number of health care providers world-wide, the coronavirus disease 2019 (COVID-19) pandemic is their first experience in population-based care. In past decades, lower population densities, infectious disease outbreaks, epidemics, and pandemics were rare and driven almost exclusively by natural disasters, predatory animals, and war. In the early 1900s, Sir William Osler first advanced the knowledge of zoonotic diseases that are spread from reservoir animals to human animals. Once rare, they now make up 71% or more of new diseases. Globally, zoonotic spread occurs for many reasons. Because the human population has grown in numbers and density, the spread of these diseases accelerated though rapid unsustainable urbanization, biodiversity loss, and climate change. Furthermore, they are exacerbated by an increasing number of vulnerable populations suffering from chronic deficiencies in food, water, and energy. The World Health Organization (WHO) and its International Health Regulation (IHR) Treaty, organized to manage population-based diseases such as Influenza, severe acute respiratory syndrome (SARS), H1N1, Middle East respiratory syndrome (MERS), HIV, and Ebola, have failed to meet population-based expectations. In part, this is due to influence from powerful political donors, which has become most evident in the current COVID-19 pandemic. The global community can no longer tolerate an ineffectual and passive international response system, nor tolerate the self-serving political interference that authoritarian regimes and others have exercised over the WHO. In a highly integrated globalized world, both the WHO with its IHR Treaty have the potential to become one of the most effective mechanisms for crisis response and risk reduction world-wide. Practitioners and health decision-makers must break their silence and advocate for a stronger treaty, a return of the WHO's singular global authority, and support highly coordinated population-based management. As Osler recognized, his concept of "one medicine, one health" defines what global public health is today.
    Frederick M. Burkle Jr. 4/2020. “Declining Public Health Protections within Autocratic Regimes: Impact on Global Public Health Security, Infectious Disease Outbreaks, Epidemics, and Pandemics.” Prehospital and Disaster Medicine. Read PublicationAbstract
    Public health emergencies of international concern, in the form of infectious disease outbreaks, epidemics, and pandemics, represent an increasing risk to the worldʼs population. Management requires coordinated responses, across many disciplines and nations, and the capacity to muster proper national and global public health education, infrastructure, and prevention measures. Unfortunately, increasing numbers of nations are ruled by autocratic regimes which have characteristically failed to adopt investments in public health infrastructure, education, and prevention measures to keep pace with population growth and density. Autocratic leaders have a direct impact on health security, a direct negative impact on health, and create adverse political and economic conditions that only complicate the crisis further. This is most evident in autocratic regimes where health protections have been seriously and purposely curtailed. All autocratic regimes define public health along economic and political imperatives that are similar across borders and cultures. Autocratic regimes are seriously handicapped by sociopathic narcissistic leaders who are incapable of understanding the health consequences of infectious diseases or the impact on their population. A cross section of autocratic nations currently experiencing the impact of COVID-19 (coronavirus disease 2019) are reviewed to demonstrate the manner where self-serving regimes fail to manage health crises and place the rest of the world at increasing risk. It is time to re-address the pre-SARS (severe acute respiratory syndrome) global agendas calling for stronger strategic capacity, legal authority, support, and institutional status under World Health Organization (WHO) leadership granted by an International Health Regulations Treaty. Treaties remain the most successful means the world has in preventing, preparing for, and controlling epidemics in an increasingly globalized world.
    Signal Program. 3/2020. Displacement & Destruction: Analysis of Idlib, Syria 2017-2020.Abstract
    As the Syrian civil war enters its tenth year on  March 15, the Signal Program on Human Security and Technology conducted satellite imagery analysis to capture the rapid expansion of displaced people’s camps and the widespread impact of aerial bombardment in Idlib, Syria. This work was completed in collaboration with Save the Children and World Vision International. On 1 March 2020, the UN estimated that 961,286 individuals have been displaced since December 1, 2019; this is the largest mass displacement and acute humanitarian crisis since the  Syrian conflict began in 2012. Analyzing two internally displaced person (IDP) camps, the Signal team found that the camp areas analyzed increased by approximately 100% and 177% respectively between September 2017 and February 2020. Camp growth between December 2019 and 2020 revealed new structures and further construction, consistent with a significant influx of displaced persons.  The UN Human Rights Council reports that between May 2019 and January 2020, aerial bombardment and a surge of ground-level assaults contributed to a wave of IDPs throughout Idlib as civilian areas were repeatedly targeted. Signal’s analysis of two areas in conflict-affected towns in southern Idlib found that approximately 30% of structures were damaged; this figure likely underestimates the total damage.
    Frederick M. Burkle Jr. 3/2020. “Opportunities Lost: Political Interference in the Systematic Collection of Population Health Data During and After the 2003 War in Iraq.” Disaster Medicine and Public Health Preparedness.Abstract

    The review of the article, “Developing a Public Health Monitoring System in a War-torn Region: A Field Report from Iraqi Kurdistan,” prompted the writing of this commentary. Decisions to implement health data systems within Iraq require exploration of many otherwise undisclosed or unknown historical facts that led to the politicization of and ultimate demise of the pre-2003 Iraq war systematic health data monitoring system designed to mitigate both direct and indirect mortality and morbidity. Absent from the field report’s otherwise accurate history leading up to and following the war is the politically led process by which the original surveillance system planned for the war and its aftermath was destroyed. The successful politicization of the otherwise extensively planned for public health monitoring in 2003 and its legacy harmed any future attempts to implement similar monitoring systems in succeeding wars and conflicts. Warring factions only collect military casualty data. The field report outlines current attempts to begin again in building a systematic health monitoring system emphasizing it is the “only way to manage the complex post-war events that continue to lead to disproportionate preventable mortality and morbidity.”

    TB Erickson, PR Chai, and EW Boyer. 2020. “Chloroquine, hydroxychloroquine and COVID-19.” Toxicol Commun, 4, 1, Pp. 40-42.Abstract
    The media have featured the antimalarials chloroquine (CQ) and hydroxychloroquine (HCQ) to treat coronavirus (COVID-19). Political leaders have touted their use and recommended availability to the public. These anti-inflammatory agents have substantial human toxicity with a narrow therapeutic window. CQ and HCQ poisoning cause myocardial depression and profound hypotension due to vasodilation. Bradycardia and ventricular escape rhythms arise from impaired myocardial automaticity and conductivity due to sodium and potassium channel blockade. With cardiotoxicity, ECGs may show widened QRS, atrioventricular heart block and QT interval prolongation. CQ may also cause seizures, often refractory to standard treatment. Of concern is pediatric poisoning, where 1-2 pills of CQ or HCQ can cause serious and potentially fatal toxicity in a toddler. The treatment of CQ/HCQ poisoning includes high-dose intravenous diazepam postulated to have positive ionotropic and antidysrhythmic properties that may antagonize the cardiotoxic effects of CQ. Infusions of epinephrine titrated to treat unstable hypotension, as well as potassium for severe hypokalemia may be required. Current scientific evidence does not support treatment or prophylactic use of these agents for COVID-19 disease. Regulatory and public health authorities recognize that CQ/HCQ may offer little clinical benefit and only add risk requiring further investigation before wider public distribution.
    Hanni Stoklosa, Nathan Kunzler, Zheng Ben Ma, Juan Carlos Jimenez Luna, Gonzalo Martinez de Vedia, and Timothy B Erickson. 2020. “Pesticide Exposure and Heat Exhaustion in a Migrant Agricultural Worker: A Case of Labor Trafficking.” Ann Emerg Med, 76, 2, Pp. 215-218.Abstract
    To our knowledge, there are no published reports of heat exhaustion and pesticide exposure in a labor trafficked patient in the literature. Here we represent the case of J.C.J.L., who was labor trafficked. He presented to a local emergency department with heat exhaustion and pesticide exposure related to working conditions in a Mississippi corn field. Unfortunately, while he received medical treatment, his labor trafficking condition was missed. Emergency departments should be equipped to assess for human trafficking and connect trafficked persons with the resources they need. Emergency physicians should maintain a high index of suspicion for human trafficking among migrant workers presenting with occupation-related complaints.
    Michael A DeLuca, Peter R Chai, Eric Goralnick, and Timothy B Erickson. 2020. “Five Decades of Global Chemical Terror Attacks: Data Analysis to Inform Training and Preparedness.” Disaster Med Public Health Prep, Pp. 1-12.Abstract
    BACKGROUND: Chemical weapons attacks during the recent conflict in Syria and Iraq highlight the need to better understand the changing epidemiology of chemical weapons use, especially among non-state actors. Public health professionals and policy-makers require this data to prioritize funding, training, chemical weapons preparedness, disaster response, and recovery. The purpose of this investigation is to provide descriptive data that can be used by policy-makers and public safety officials to better prepare for these potential attacks. METHODS: A five-decade descriptive retrospective review of The Global Terrorism Database, maintained by the National Consortium for the Study of Terrorism and Responses to Terrorism, was conducted to understand trends in chemical agents, targets, and routes of exposure. We reviewed and analyzed data specific to these documented chemical attacks between 1970 and 2017. RESULTS: 383 terror attacks involved chemical weapons over the study period. A specific agent was named in 154 incidents, while 124 incidents could be classified into traditional chemical weapons categories (eg, vesicant, choking agents). A route of exposure was identified in 242 attacks, with the most common routes of exposure being dermal-mucosal and inhalational. Caustic agents were used in the highest portion of attacks (25%) where the route of exposure was known. Explosive devices were used in 21% of attacks to deliver these chemical agents. Of particular note, private citizens and educational facilities were targeted in 25% and 12% of attacks, respectively. The average number of attacks increased from 6 per year between 1970 and 2011 to 24.9 per year between 2011 and 2017 (coinciding with the start of the Syria conflict). The most commonly utilized chemicals were chlorine (26.0%), tear gas (20.8%), and cyanide (15.6%). Blood agent incidents declined from 32.6% before the September 11, 2001 attacks to 13.6% after 2001, while nerve agent attacks fell from 9.3% to 1.2%. In contrast, choking (namely chlorine) and vesicant (mustard) agent use increased from 7% to 48.1% and from 2.3% to 6.2% of attacks, respectively. CONCLUSIONS: Chemical weapon use in global terrorism remains an increasingly common occurrence that requires better characterization. The average number of chemical terrorist attacks per year is increasing, with a large proportion resulting from the conflicts in Iraq and Syria. Choking (chlorine) and vesicant (mustard) agents have become the predominant chemical terror agent since 2001, with a decreased incidence of blood (cyanogenic) and nerve (sarin) agents. Future preparedness initiatives should focus on vulnerable targets such as private citizens and educational institutions. Improving blast injury response is essential, along with prioritizing disaster training focused on choking agents, vesicants, and caustics.
    Sonny S Patel, Robert M Grace, Patrick Chellew, Mykola Prodanchuk, Olha Romaniuk, Yuriy Skrebets, Sergii A Ryzhenko, and Timothy B Erickson. 2020. “"Emerging Technologies and Medical Countermeasures to Chemical, Biological, Radiological, and Nuclear (CBRN) Agents in East Ukraine".” Conflict and Health, 14, Pp. 24.Abstract
    Since 2014, Ukraine has been beset by an armed conflict with international and internal dimensions. The nature of this conflict is multidimensional, and disaster preparedness and response in this context must be as well. Health experts from Ukraine, the United States of America, United Kingdom, Czech Republic, and Norway convened for an educational event in Dnipro, East Ukraine on November 11-15, 2019. At the event, "Emerging Technologies and Countermeasures to CBRN Agents: Advanced Training Response to Conflict and Security Challenges in East Ukraine," over 1,000 participants participated in panel discussions, didactic lectures, and an advanced training on various dimensions of disaster response. This report provides an overview of the key discussions and outcomes of the event.
    Norkio Endo, Newsha Ghaeli, Claire Duvallet, Katelyn Foppe, Timothy B Erickson, Mariana Matus, and Peter R Chai. 2020. “Rapid Assessment of Opioid Exposure and Treatment in Cities Through Robotic Collection and Chemical Analysis of Wastewater.” J Med Toxicol, 16, 2, Pp. 195-203.Abstract
    INTRODUCTION: Accurate data regarding opioid use, overdose, and treatment is important in guiding community efforts at combating the opioid epidemic. Wastewater-based epidemiology (WBE) is a potential method to quantify community-level trends of opioid exposure beyond overdose data, which is the basis of most existing response efforts. However, most WBE efforts collect parent opioid compounds (e.g., morphine) at wastewater treatment facilities, measuring opioid concentrations across large catchment zones which typically represent an entire municipality. We sought to deploy a robotic sampling device at targeted manholes within a city to semi-quantitatively detect opioid metabolites (e.g., morphine glucuronide) at a sub-city community resolution. METHODS: We deployed a robotic wastewater sampling platform at ten residential manholes in an urban municipality in North Carolina, accounting for 44.5% of the total municipal population. Sampling devices comprised a robotic sampling arm with in situ solid phase extraction, and collected hourly samples over 24-hour periods. We used targeted mass spectrometry to detect the presence of a custom panel of opioids, naloxone, and buprenorphine. RESULTS: Ten sampling sites were selected to be a representative survey of the entire municipality by integrating sewer network and demographic GIS data. All eleven metabolites targeted were detected during the program. The average morphine milligram equivalent (MME) across the nine illicit and prescription opioids, as excreted and detected in wastewater, was 49.1 (standard deviation of 31.9) MME/day/1000-people. Codeine was detected most frequently (detection rate of 100%), and buprenorphine was detected least frequently (12%). The presence of naloxone correlated with city data of known overdoses reversed by emergency medical services in the prehospital setting. CONCLUSION: Wastewater-based epidemiology with smart sewer selection and robotic wastewater collection is feasible to detect the presence of specific opioids, naloxone, methadone, and buprenorphine within a city. These results suggest that wastewater epidemiology could be used to detect patterns of opioid exposure and may ultimately provide information for opioid use disorder (OUD) treatment and harm reduction programs.

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