Hanni Stoklosa, Courtney Julia Burns, Abraar Karan, Michelle Lyman, Nathene Morley, Reena Tadee, and Eric Goodwin. 6/2021. “Mitigating trafficking of migrants and children through disaster risk reduction: Insights from the Thailand flood.” International Journal of Disaster Risk Reduction. Read PublicationAbstract

Thailand's flood of 2011 was devastating for the communities and inhabitants of the country, affecting approximately 13 million people and causing damages totaling THB 1.43 trillion (46.5 billion USD). The presence of a natural hazards disaster such as this can magnify individuals' vulnerability to human trafficking, or mitigate it depending on the disaster risk reduction practices of the surrounding community. The Sendai Framework is the United Nations Office for Disaster Risk Reduction's international framework for these situations, outlining targets and priorities for action to reduce negative outcomes, such as trafficking, from natural events. This study aimed to understand how a disaster risk reduction and preparedness lens, based on the Sendai Framework, in the context of the humanitarian response to this 2011 flood, could inform human trafficking prevention efforts for future disasters. Qualitative methodology, utilizing a content analysis approach, was employed. It was found that migrant workers and children were at the greatest risk for trafficking, and resiliency efforts by communities and families, in conjunction with coordinated initiatives by NGOs and the government, were essential in preserving individuals' well-being. Further, the Sendai Framework is a promising tool to address these areas of disaster response in which the windows of opportunity for traffickers can be closed and those at high trafficking risk can be protected. As disasters continue to occur, there remains a strong need to bring forth a more systematic disaster risk reduction and resilience-enhancing approach to trafficking prevention.

P.N. Pham, L. Fozouni, and al-Saiedi. 4/8/2021. “Association between distress and displacement settings: a cross-sectional survey among displaced Yazidis in northern Iraq.”  BMC Public Health, 21, 679. Publisher's VersionAbstract

Globally 70.8 million people have been forcibly displaced from their homes and are at disproportionally high risk for trauma. At the time of this study, there was an estimated 1.6 million internally displaced persons (IDP) in Iraq, more than two-thirds of whom reside in private, urban settings. This study aims to understand the impact of post-displacement accommodation on mental well-being of the Yazidi minority group displaced in Iraq.

Multi-stage stratified sampling was used to randomly select IDPs in camp and out of camp settlements in northern Iraq. Standardized questionnaires evaluated factors including exposure to violence and self-reported distress symptoms (measured by Impact of Event Scale-Revised). A multi-variate linear model assessed the relationship between settlement setting and distress symptoms.

One thousand two hundred fifty-six displaced Yazidi participants were included in the study: 63% in camps and 37% out of camps. After controlling for exposure to violence, social cohesion, unemployment, and access to basic services, IDPs in camps were predicted to have a 19% higher mean distress symptom score compared to those out of camps.

This study provides a framework to investigate post-displacement accommodation as a potential intervention to improve well-being for displaced populations. With a shift towards new models of emergency and long-term housing, it is important to understand the potential and limitations of more decentralized models, and identify effective methods to maintain access to basic services while improving living conditions for both displaced populations and their host communities.

Adrienne Fricke and Rahaf Safi. 3/2021. Window of Hope: Sustaining education of health professionals in northwest Syria.Abstract
This report is based on a comprehensive needs assessment carried out remotely by the HHI team in Syria in 2019. The OSF HESP grant was awarded to a larger project to understand the impact of humanitarian emergencies, including armed conflict, on students enrolled in medical and nursing programs. The goal is to produce a needs assessment toolkit to help support professional health care education programs during conflict. In addition to Syria, where the conflict is ongoing, the project examines Colombia, a recent post-conflict setting, and Rwanda, a developed post-conflict setting.
Amir Khorram-Manesh, Phatthranit Phattharapornjaroen, Luc J Mortelmans, and Frederick M. Burkle Jr. 2/2021. “Current Perspectives and Concerns Facing Hospital Evacuation: The Results of a Pilot Study and Literature Review.” Disaster Medicine and Public Health Preparedness. Read PublicationAbstract

Objective: To analyze the evacuation preparedness of hospitals within the European Union (EU).

Method: This study consisted of 2 steps. In the first step, a systematic review of the subject matter, according to the PRISMA flow diagram, was performed. Using Scopus (Elsevier, Amsterdam, Netherlands), PubMed (National Library of Medicine, Bethesda, MD), and Gothenburg University´s search engine, 11 questions were extracted from the review and were sent to representatives from 15 European Union (EU)- and non-EU countries.

Results: The findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the EU or other non-EU countries in this study. A major shortcoming revealed by this study is the lack of awareness of the untoward consequences of medical decision-making during an evacuation. Some countries did not respond to the questions due to the lack of relevant guidelines, instructions, or time.

Conclusion: Hospitals are exposed to internal and external incidents and require an adequate evacuation plan. Despite many publications, reports, and conclusions on successful and unsuccessful evacuation, there is still no common guide for evacuation, and many hospitals lack the proper preparedness. There is a need for a multinational collaboration, specifically within the EU, to establish such an evacuation planning or guideline to be used mutually within the union and the international community.

Krzysztof Goniewicz, Mariusz Goniewicz, Frederick M. Burkle Jr., and Amir Khorram-Manesh. 1/2021. “Cohort research analysis of disaster experience, preparedness, and competency-based training among nurses.” PLoS ONE. Read PublicationAbstract

Introduction: It is expected that in unforeseen situations, nurses will provide appropriate medical interventions, using their expertise and skills to reduce the risks associated with the consequences of disasters. Consequently, it is crucial that they are properly prepared to respond to such difficult circumstances. This study aimed to identify the factors influencing the basic competences of nurses in disasters.

Materials and methods: The survey was directed to 468 nurses from all medical centres in Lublin. IBM SPSS Statistics version 23 was used for statistical analyses, frequency analysis, basic descriptive statistics and logistic regression analysis. The classical statistical significance level was adopted as α = 0.05.

Results: Based on the logistic regression analysis, it was found that work experience, workplace preparedness, as well as training and experience in disaster response are important predictors of preparedness.

Conclusions: These findings indicate that the nurses' core competencies for these incidents can be improved through education and training programmes which increase their preparedness for disasters. Nurses are among the most important groups of healthcare professionals facing a disaster and should be involved in all phases of disaster management, such as risk assessment and pre-disaster planning, response during crisis situations and risks’ mitigation throughout the reconstruction period.

Krzysztof Goniewicz, Mariusz Goniewicz, Anna Włoszczak-Szubzda, Frederick M. Burkle Jr., Attila J. Hertelendy, Ahmed Al-Wathinani, Michael Sean Molloy, and Amir Khorram-Manesh. 1/2021. “The importance of pre-training gap analyses and the identification of competencies and skill requirements of medical personnel for mass casualty incidents and disaster training.” BMC Public Health.Abstract

Background: Effective preparedness to respond to mass casualty incidents and disasters requires a well-planned and integrated effort by all involved professionals, particularly those who are working in healthcare, who are equipped with unique knowledge and skills for emergencies. This study aims to investigate and evaluate the level of knowledge and skills related to mass casualty and disaster management in a cohort of healthcare professionals.

Methods: A cross-sectional brief study was conducted using a validated and anonymous questionnaire, with a sample of 134 employees at a clinical hospital in Lublin, Poland.

Results: The findings of this study may indicate a need for standardization of training for hospitals employees. It also suggests a knowledge gap between different professional groups, which calls for adjusting such general training, to at least, the weakest group, while special tasks and mission can be given to other groups within the training occasion.

Conclusion: Pre-Training gap analyses and identification of participants’ competencies and skills should be conducted prior to training in mass casualty incidents and disasters. Such analyses provides an opportunity to develop training curriculum at various skill and knowledge levels from basic to advance. All training in mass casualty incidents and disasters should be subject to ongoing, not just periodic, evaluation, in order to assess continued competency.

Amir Khorram-Manesh, Krzysztof Goniewicz, and Frederick M. Burkle Jr. 1/2021. “Unrecognized risks and challenges of water as a major focus of COVID-19 spread.” Journal of Global Health . Read PublicationAbstract

The unpredictable emergence of Coronavirus 2019 has proven to be challenging for many countries and their preparedness systems. In the heat of the current pandemic, initial interventions have been directed to the medical component of pandemic management, while other parameters such as tracing, retaining, and controlling the infection have been dismantled. It must be remembered that a defective water management system for drinking or personal use cannot only worsen the medical management of an emergency but can also contribute to spreading the disease or other water-borne conditions. This report highlights the significant use of water as a necessity for life and for controlling the pandemic.

Scott A. Goldberg, Rebecca E. Cash, Gregory Peters, Scott G.Weiner, P. Gregg Greenough, and Raghu Seethala. 2021. “The impact of COVID‐19 on statewide EMS use for cardiac emergencies and stroke in Massachusetts.” JACEP Open. Publisher's VersionAbstract


To evaluate the impact of coronavirus disease 2019 (COVID‐19) on emergency medical services (EMS) use for time‐sensitive medical conditions. We examined EMS use for cardiac arrest, stroke, and other cardiac emergencies across Massachusetts during the peak of the COVID‐19 pandemic, evaluating their relationship to statewide COVID‐19 incidence and a statewide emergency declaration.


A retrospective analysis of all EMS calls between February 15 and May 15, 2020 and the same time period for 2019. EMS call volumes were compared before and after March 10, the date of a statewide emergency declaration.


A total of 408,758 calls were analyzed, of which 49,405 (12.1%) represented stroke, cardiac arrest, or other cardiac emergencies. Average call volume before March 10 was similar in both years but decreased significantly after March 10, 2020 by 18.7% (P < 0.001). Compared to 2019, there were 35.6% fewer calls for cardiac emergencies after March 10, 2020 (153.6 vs 238.4 calls/day, P < 0.001) and 12.3% fewer calls for stroke (40.0 vs 45.6 calls/day, P = 0.04). Calls for cardiac arrest increased 18.2% (28.6 vs 24.2 calls/day, P < 0.001). Calls for respiratory concerns also increased (208.8 vs 199.7 calls/day, P < 0.001). There was no significant association between statewide incidence of COVID‐19 and EMS call volume.


EMS use for certain time‐sensitive conditions decreased after a statewide emergency declaration, irrespective of actual COVID‐19 incidence, suggesting the decrease was related to perception instead of actual case counts. These findings have implications for public health messaging. Measures must be taken to clearly inform the public that immediate emergency care for time‐sensitive conditions remains imperative.

PR Chai, EG Ferro, JM Kirshenbaum, BD Hayes, SE Culbreth, EW Boyer, and TB Erickson. 2021. “In Reply to "Hydroxychloroquine Overdose: What Are the Exact Roles of Diazepam and Potassium Infusion?"” J Med Toxicol, 17, 1, Pp. 85-86.
Amir Khorram-Manesh and Frederick M. Burkle Jr. 12/2020. Emergencies and Public Health Crisis Management-Current Perspectives on Risks and Multiagency Collaboration. MDPI.Abstract

Disasters and public health emergencies are inevitable and can happen anywhere and anytime. However, they can be mitigated and their impacts can be minimized by utilizing appropriate measures in all four different phases of disaster management, i.e., mitigation and prevention, preparedness, response, and recovery. Several factors are crucial for achieving successful disaster management. Altogether, this Issue offers new insights into emergency and public health crisis management from a multiagency perspective and allows discussion about new potential risks; lessons learned; and the introduction of new concepts such as flexible surge capacity, and shows some new aspects of practicing multiagency collaboration before, during, and after disasters and public health emergencies.

Krzysztof Goniewicz, Frederick M. Burkle Jr., and Amir Khorram-Manesh. 12/2020. “Implications and limitations of Social Distancing Strategies (SDS) to mitigate the impact of COVID-19 pandemic.” Disaster Medicine and Public Health Preparedness. implications-and-limitations-of-social-distancing.pdf
Erica Nelson, Saira Khan, Swapna Thorve, and P. Gregg Greenough. 12/2020. “Modeling pastoralist movement in response to environmental variables and conflict in Somaliland: Combining agent-based modeling and geospatial data.” PLOS ONE.Abstract

This study explores how pastoralists respond to changing environments in Somaliland . An agent-based model is used to simulate the movement of nomadic pastoralists based on typologically diverse, historical data of environmental, interpersonal, and transactional variables in Somaliland and Puntland between 2008 and 2018. Through subsequent application of spatial analysis such as choropleth maps, kernel density mapping, and standard deviational ellipses, we characterize the resultant pastoralist population distribution in response to these variables.

Amir Khorram-Manesh, Frederick M. Burkle Jr., Phatthranit Phattharapornjaroen, Milad Ahmadi Marzaleh, Mohammed Al Sultan, Matti Mantysaari, Eric Carlström, Krzysztof Goniewicz, Emelia Santamaria, John David Comandante, Robert Dobson, Boris Hreckovski, Glenn-Egil Torgersen, Luc J. Mortelmans, Mirjam de Jong, and Yohan Robinson. 11/2020. “The Development of Swedish Military Healthcare System: Part II-Re-evaluating the Military and Civilian Healthcare Systems in Crises Through a Dialogue and Study Among Practitioners.” Military Medicine.Abstract

Introduction: Historical changes have transformed Sweden from being an offensive to a defensive and collaborative nation with national and international engagement, allowing it to finally achieve the ground for the civilian–military collaboration and the concept of a total defense healthcare. At the same time, with the decreasing number of international and interstate conflicts, and the military’s involvement in national emergencies and humanitarian disaster relief, both the need and the role of the military healthcare system within the civilian society have been challenged. The recent impact of the COVID-19 in the USA and the necessity of military involvement have led health practitioners to anticipate and re-evaluate conditions that might exceed the civilian capacity of their own countries and the need to have collaboration with the military healthcare. This study investigated both these challenges and views from practitioners regarding the benefits of such collaboration and the manner in which it would be initiated.

Material and Method: A primary study was conducted among responsive countries using a questionnaire created using the Nominal Group Technique. Relevant search subjects and keywords were extracted for a systematic review of the literature, according to the PRISMA model.

Results: The 14 countries responding to the questionnaire had either a well-developed military healthcare system or units created in collaboration with the civilian healthcare. The results from the questionnaire and the literature review indicated a need for transfer of military medical knowledge and resources in emergencies to the civilian health components, which in return, facilitated training opportunities for the military staff to maintain their skills and competencies.

Conclusions: As the world witnesses a rapid change in the etiology of disasters and various crises, neither the military nor the civilian healthcare systems can address or manage the outcomes independently. There is an opportunity for both systems to develop future healthcare in collaboration. Rethinking education and training in war and conflict is indisputable. Collaborative educational initiatives in disaster medicine, public health and complex humanitarian emergencies, international humanitarian law, and the Geneva Convention, along with advanced training in competency-based skill sets, should be included in the undergraduate education of health professionals for the benefit of humanity.

Robert I.S. Macpherson and Frederick M. Burkle Jr. 11/2020. “Humanitarian Aid Workers: The Forgotten First Responders.” Prehospital and Disaster Medicine. Read PublicationAbstract

Humanitarian aid workers are an overlooked population within the structure of posttraumatic stress disorder (PTSD) research and assistance. This negligence is an industry-wide failure to address aid workers’ psychological health issues. The suspected numbers of death by suicide, diagnosed PTSD, depression, anxiety disorders, hazardous alcohol and drug consumption, emotional exhaustion, and other stress-related problems are impossible to quantify but are considered endemic. Tools for establishing organizational frameworks for mental health and psychosocial support are readily available. However, the capacity to implement this assistance requires the creation and practice of an open and non-judgmental culture, based on the realistic acceptance that aid work has become inherently dangerous. The possibility of developing a psychological problem because of aid work has increased along with the rise in levels of disease, injury, kidnapping, and assault. As a result, expressions of traumatic stress have become the norm rather than an exception. This commentary outlines the essential steps and components necessary to meet these requirements.

MPH P. Gregg Greenough, MD, Ravi Goyal, Ruwan Ratnayake, Fatma Rawashdeh, Raeda AbuAlRub, Nahla Al-Ali, Muhammad Fawad, and Mohammad Bani Han. 10/14/2020. “Access to Care and Prevalence of Hypertension and Diabetes Among Syrian Refugees in Northern Jordan.” JAMA Network Open. Publisher's VersionAbstract

Importance  The management of noncommunicable diseases in humanitarian crises has been slow to progress from episodic care. Understanding disease burden and access to care among crisis-affected populations can inform more comprehensive management.

Objective  To estimate the prevalence of hypertension and diabetes with biological measures and to evaluate access to care among Syrian refugees in northern Jordan.

Design, Setting, and Participants  This cross-sectional study was undertaken from March 25 to April 26, 2019, in the districts of Ramtha and Mafraq, Jordan. Seventy clusters of 15 households were randomly sampled, and chain referral was used to sample Syrian households, representative of 59 617 Syrian refugees. Adults were screened and interviewed about their access to care. Data analysis was performed from May to September 2019.

Exposures  Primary care delivered through a humanitarian organization since 2012.

Main Outcomes and Measures  The main outcomes were self-reported prevalence of hypertension and diabetes among adults aged 18 years or older and biologically based prevalence among adults aged 30 years or older. The secondary outcome was access to care during the past month among adults aged 18 years or older with a diagnosis of hypertension or diabetes.

Results  In 1022 randomly sampled households, 2798 adults aged 18 years or older, including 275 with self-reported diagnoses (mean [SD] age, 56.5 [13.2] years; 174 women [63.3%]), and 915 adults aged 30 years or older (608 women [66.5%]; mean [SD] age, 46.0 [12.8] years) were screened for diabetes and hypertension. Among adults aged 18 years or older, the self-reported prevalence was 17.2% (95% CI, 15.9%-18.6%) for hypertension, 9.8% (95% CI, 8.6%-11.1%) for diabetes, and 7.3% (95% CI, 6.3%-8.5%) for both conditions. Among adults aged 30 years or older, the biologically based prevalence was 39.5% (95% CI, 36.4%-42.6%) for hypertension, 19.3% (95% CI, 16.7%-22.1%) for diabetes, and 13.5% (95% CI, 11.4%-15.9%) for both conditions. Adjusted for age and sex, prevalence for all conditions increased with age, and women had a higher prevalence of diabetes than men (adjusted prevalence ratio, 1.3%; 95% CI, 1.0%-1.7%), although the difference was not significant. Complications (57.4%; 95% CI, 51.5%-63.1%) and obese or overweight status (82.8%; 95% CI, 79.7%-85.5%) were highly prevalent. Among adults aged 30 years or older with known diagnoses, 94.1% (95% CI, 90.9%-96.2%) currently took medication. Among adults aged 18 years or older with known diagnoses, 26.8% (95% CI, 21.3%-33.1%) missed a medication dose in the past week, and 49.1% (95% CI, 43.3%-54.9%) sought care in the last month.

Conclusions and Relevance  During this protracted crisis, obtaining care for noncommunicable diseases was feasible, as demonstrated by biologically based prevalence that was only moderately higher than self-reported prevalence. The high prevalence of complications and obese or overweight status, however, suggest inadequate management. Programs should focus on reinforcing adherence and secondary prevention to minimize severe morbidity.

Krzysztof Goniewicz, Mariusz Goniewicz, Frederick M. Burkle Jr., and Amir Khorram-Manesh. 10/2020. “The Impact of Experience, Length of Service, and Workplace Preparedness in Physicians' Readiness in the Response to Disasters.” Journal of Clinical Medicine.Abstract
With an increasing number of natural and man-made disasters, the need for preparedness in all levels of management is obvious. Among healthcare professionals responding to these emergencies, physicians are of particular importance due to their significant roles as leaders and frontline workers in minimizing morbidity and mortality of the affected population. This study analyses the preparedness of 549 physicians from all medical centers in Lublin, Poland to formulate their observations, suggestions, and recommendations concerning the improvement of the chain of response in disaster management. The results of this study show that the perceived preparedness of physicians for disaster management and response is not as high as it should be, and the majority of the respondents perceived their disaster preparedness insufficient. Training of physicians in disaster management and principles of disaster medicine is needed, by focusing on the specificity of rescue response to emergencies following disasters, and medical and non-medical aspects of the response with particular emphasis on a management approach covering all hazards.
Phuong Pham, Vincenzo Bollettino, Patrick Vinck, Ariana Marnicio, Lea Ivy Manzanero, Mark Toldo, Rachel Dickinson, Alexis Smart, and Evan Bloom. 10/2020. “Network Analysis of Actors Working to Support Disaster Preparedness and Resilience in the Philippines”.Abstract
The Harvard Humanitarian Initiative (HHI) partnered with Root Change to conduct a network analysis of actors working to support disaster preparedness and resilience in the Philippines. The study design is modeled after a summative phase external evaluation that HHI conducted in 2016-2017 on the START Network’s Disasters and Emergency Preparedness Program (DEPP). Network analysis techniques applied in this evaluation have been adapted from the DEPP work to analyze the disaster resilience network in coastal Bangladesh under the Resilient Communities Program. In this report, we present the network analysis and methods used. We also detail findings and recommendations for HHI and other in-country partners about how these results can inform programs to strengthen disaster resilience and climate change in the Philippines.
Amir Khorram-Manesh and Frederick M. Burkle Jr. 10/2020. “Sustainability Editorial Disasters and Public Health Emergencies-Current Perspectives in Preparedness and Response.” Sustainability. Read PublicationAbstract

Disasters and public health emergencies are inevitable and can happen anywhere and anytime. However, they can be mitigated and their impacts can be minimized by utilizing appropriate measures in all four different phases of disaster management, i.e., mitigation and prevention, preparedness, response, and recovery. Several factors are crucial for achieving successful disaster management. In the mitigation and preparation phase, all risks should be reviewed and new ones should be added and analyzed carefully to propose proper solutions and plans. In the preparedness phase, the ability and knowledge of each organization and all individuals in the management system should be tested and evaluated to ensure good readiness in responding to an emergency. Furthermore, plans should be available at all levels of the emergency chain of action to cope with all issues in the response and recovery phases [1,2]. This Issue of Sustainability aimed to cover emergency and public health crisis management from a multiagency perspective, by discussing lessons learned, introducing new ideas about flexible surge capacity, and showing the way it can practice multiagency collaboration.

Frederick M. Burkle Jr., David A. Bradt, Joseph Green, and Benjamin J. Ryan. 10/2020. “Global Public Health Database Support to Population-Based Management of Pandemics and Global Public Health Crises, Part II: The Database.” Prehospital and Disaster Medicine. Read PublicationAbstract

This two-part article examines the global public health (GPH) information system deficits emerging in the coronavirus disease 2019 (COVID-19) pandemic. It surveys past, missed opportunities for public health (PH) information system and operational improvements, examines current megatrend changes to information management, and describes a new multi-disciplinary model for population-based management (PBM) supported by a GPH Database applicable to pandemics and GPH crises.

Frederick M. Burkle Jr., David A. Bradt, and Benjamin J. Ryan. 10/2020. “Global Public Health Database Support to Population-Based Management of Pandemics and Global Public Health Crises, Part I: The Concept.” Prehospital and Disaster Medicine. Read PublicationAbstract
This two-part article examines the global public health (GPH) information system deficits emerging in the coronavirus disease 2019 (COVID-19) pandemic. It surveys past, missed opportunities for public health (PH) information system and operational improvements, examines current megatrend changes to information management, and describes a new multi-disciplinary model for population-based management (PBM) supported by a GPH Database applicable to pandemics and GPH crises.