Publications by Year: 2020

Objectives: Biological weapons are one of the oldest weapons of mass destruction used by man. Their use has not only determined the outcome of battles, but also influenced the fate of entire civilizations. Although the use of biological weapons agents in a terrorist attack is currently unlikely, all services responsible for the surveillance and removal of epidemiological threats must have clear guidelines and emergency response plans.

Methods: In the face of the numerous threats appearing in the world, it has become necessary to put the main emphasis on modernizing, securing, and maintaining structures in the field of medicine which are prepared for unforeseen crises and situations related to the use of biological agents.

Results: This article presents Poland’s current preparation to take action in the event of a bioterrorist threat. The study presents both the military aspect and procedures for dealing with contamination.

Conclusions: In Poland, as in other European Union countries fighting terrorism, preparations should be made to defend against biological attacks, improve the flow of information on the European security system, strengthen research centers, train staff, create observation units and vaccination centers, as well as prepare hospitals for the hospitalization of patients—potential victims of bioterrorist attacks.

Interview: At first sight, Population-based Triage, PBT for short, isn't the most enticing social formula-but it may be the key to how the UK manages the next stages of the current Corona quagmire-and prepare for the next one, when and not if it happens. It could, and probably should, become standard operating procedure in public health population-based management decisions in the outbreak of widespread pestilence and disease. We need that new Public Health Strategy now. Under the PBT plan the population as a whole is treated to the triage technique familiar in accident and emergency, and battlefield medicine. Medical and rescue teams concentrate on treating the salvageable in preference to those most likely to die. "Traditional health care systems care systems care for patients individually, while public health is caring for an entire population," says Professor Frederick Burkle, Senior Scholar and Scientist of Public Health at Harvard. He published his plan for a population-based approach to pandemic in 2006. It was used in the major desk-top exercise by Public Health England for tackling a major influenza pandemic, Operation Cygnus, in 2016. The report partly adopted the professor's clear-eyed approach to running a major pandemic operation, but left many questions open. If they had been addressed in the present Covid crisis, thousands of lives might have bene saved. Much the same goes for Exercise Isis carried out by National Health Scotland in 2018, focused on a major outbreak of MERS (Middle East Respiratory Syndrome). The lessons of both exercises have been taken aboard, according to Matt Hancock, but as they say in Scots law, it looks like a case of not proven. Both the Cygnus and Isis reports of 2017 and 2018 cannot conceal the serious shortcomings in preparation against a major public health emergency. The Cygnus exercise, for instance concentrates on the role of the Local Resilience Forums in coordinating emergency services-yet the representatives of the eight LRFs were explicit about their lack of resources. The LRFs have proved vital since March, but they have no statutory powers and no funding. More ominously the Isis report for the Scottish Health flags up the lack of availability of protective equipment-PPE-for a nationwide viral outbreak. The problem of managing a workable Public Health Emergency strategy for this coronavirus crisis is brilliantly illustrated BBC1's drama documentary, The Salisbury Poisonings. It tells the real events of the attack by the nerve agent Novichok on the Skripals in Salisbury two years ago. The heroine is the Wiltshire Public Health Officer Tracy.

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.

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.

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.

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.

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.

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.

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.

This Harvard Humanitarian Initiative Annual Report covers the 2018-2019 period of activities. Within it readers can find an overview of HHI's humanitarian research & efforts, including HHI's role at Harvard University and finances for the time period.

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.

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.

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.”

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.

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.