# Publications

2020
Fuqing Wu, Amy Xiao, Jianbo Zhang, Katya Moniz, Noriko Endo, Federica Armas, Richard Bonneau, Megan A Brown, Mary Bushman, Peter R Chai, Claire Duvallet, Timothy B Erickson, Katelyn Foppe, Newsha Ghaeli, Xiaoqiong Gu, William P Hanage, Katherine H Huang, Wei Lin Lee, Mariana Matus, Kyle A McElroy, Jonathan Nagler, Steven F Rhode, Mauricio Santillana, Joshua A Tucker, Stefan Wuertz, Shijie Zhao, Janelle Thompson, and Eric J Alm. 2020. “SARS-CoV-2 titers in wastewater foreshadow dynamics and clinical presentation of new COVID-19 cases.” medRxiv.Abstract
Current estimates of COVID-19 prevalence are largely based on symptomatic, clinically diagnosed cases. The existence of a large number of undiagnosed infections hampers population-wide investigation of viral circulation. Here, we use longitudinal wastewater analysis to track SARS-CoV-2 dynamics in wastewater at a major urban wastewater treatment facility in Massachusetts, between early January and May 2020. SARS-CoV-2 was first detected in wastewater on March 3. Viral titers in wastewater increased exponentially from mid-March to mid-April, after which they began to decline. Viral titers in wastewater correlated with clinically diagnosed new COVID-19 cases, with the trends appearing 4-10 days earlier in wastewater than in clinical data. We inferred viral shedding dynamics by modeling wastewater viral titers as a convolution of back-dated new clinical cases with the viral shedding function of an individual. The inferred viral shedding function showed an early peak, likely before symptom onset and clinical diagnosis, consistent with emerging clinical and experimental evidence. Finally, we found that wastewater viral titers at the neighborhood level correlate better with demographic variables than with population size. This work suggests that longitudinal wastewater analysis can be used to identify trends in disease transmission in advance of clinical case reporting, and may shed light on infection characteristics that are difficult to capture in clinical investigations, such as early viral shedding dynamics.
DJ Tonellato, JR Ransohoff, C Nash, SEF Melanson, AK Petrides, NV Tolan, SA Goldberg, EW Boyer, PR Chai, and TB Erickson. 2020. “Traumatic pedestrian and bicyclist injuries associated with intoxication.” Am J Emerg Med.Abstract
BACKGROUND: Drug and alcohol use are risk factors for trauma among operators of motor vehicles and contribute to trauma in pedestrians and bicyclists. We describe the prevalence of drug and alcohol use and clinical consequences in a cohort of pedestrians and bicyclists with trauma. METHODS: We analyzed a 25-month data set of 916 trauma team activations from January 2017-January 2019 at an urban, level I trauma center. Blood ethanol levels and urine toxicology screens were obtained in 94 pedestrian and bicyclist trauma activations. We compared pedestrians or bicyclists with a positive urine or blood screen (n = 69) to those with negative screens (n = 25). We conducted a retrospective chart review to determine mechanism of injury, injury pattern, and disposition from the emergency department (ED). RESULTS: Overall, 38 (55%) of injured patients with positive screen were pedestrians and 31 (45%) were bicyclists. Fentanyl was the most commonly detected drug (n = 38; 40%), followed by opiates (n = 27; 29%), and tetrahydrocannabiol (THC) (n = 23; 25%). Twenty-one patients were positive for ethanol. Pedestrians and bicyclists with positive toxicology screens were significantly more likely to sustain fractures (p < .01), require an operative procedure (p < .05), or intensive care unit admission (p < .05). CONCLUSION: Our study builds on previous literature which suggests that intoxicated bicyclists and pedestrians suffer frequent and more severe injury than their sober counterparts. Public health campaigns should educate bicyclists and pedestrians about the risks of cycling or walking in areas of road traffic while under the influence of alcohol or illicit drugs.
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.
2019
Craig Etcheson. 11/2019. Extraordinary Justice: Law, Politics, and the Khmer Rouge Tribunals. Columbia University Press.
Saira Khan, Rob Baker, Caitlin Howarth, Erica Nelson, Isaac Baker, Natalia Adler, and Stefaan Verhulst. 11/2019. Lessons Learned Report: Using Satellite Data Analysis in Conflict/Famine-Affected Areas.Abstract
This report captures the lessons learned during a project titled, “Children on the Move: Using Satellite Data Analysis in Conflict/Famine-Affected Areas.” This document details the project’s progression and the rationale for transitioning from satellite imagery analysis to agent-based modeling as the primary mode of analysis. This project was conducted in collaboration with the Governance Lab at New York University, the Signal Program on Human Security and Technology at Harvard Humanitarian Initiative, and UNICEF.
Saira Khan, Isaac Baker, and Rob Baker. 11/2019. Satellite Imagery Interpretation Guide of Landscape Features in Somaliland.Abstract

This guide outlines the tools and techniques to establish a foundation for visual analysis and discusses how these techniques can assist in identifying notable landscape features pertaining to agriculture, settlements, water catchment, and livestock in northern Somalia. To the knowledge of the Signal Program analysts, there is no systematic open-source remote sensing documentation of frequently occurring natural and man-made features in Somalia. This guide helps users to identify and analyze these features, particularly humanitarian practitioners supporting activities in the Horn of Africa. This project, titled “Children on the Move: Using Satellite Data Analysis in Conflict/Famine-Affected Areas,” was carried out in collaboration with UNICEF, the GovLab at NYU, and the Signal Program on Human Security and Technology at Harvard Humanitarian Initiative.

Sylvia Kehlenbrink, James Smith, Eimhin Ansbro, Daniela C Fuhr, Anson Cheung, and Ruwan Ratnayake. 8/1/2019. “The burden of diabetes and use of diabetes care in humanitarian crises in low-income and middle-income countries.” The Lancet, 7, 8, Pp. 638-647.Abstract
Human suffering as a result of natural disasters or conflict includes death and disability from non-communicable diseases, including diabetes, which have largely been neglected in humanitarian crises. The objectives of this Series paper were to examine the evidence on the burden of diabetes, use of health services, and access to care for people with diabetes among populations affected by humanitarian crises in low-income and middle-income countries, and to identify research gaps for future studies. We reviewed the scientific literature on this topic published between 1992 and 2018. The results emphasise that the burden of diabetes in humanitarian settings is not being captured, clinical guidance is insufficient, and diabetes is not being adequately addressed. Crisis-affected populations with diabetes face enormous constraints accessing care, mainly because of high medical costs. Further research is needed to characterise the epidemiology of diabetes in humanitarian settings and to develop simplified, cost-effective models of care to improve the delivery of diabetes care during humanitarian crises.
Sylvia Kehlenbrink and Lindsay M Jaacks. 6/6/2019. “Diabetes in humanitarian crises: the Boston Declaration.” The Lancet, 7, 8. Publisher's VersionAbstract
Nearly three out of every four deaths worldwide in 2017 were caused by non-communicable diseases (NCDs). Many countries have made progress reducing risk factors for NCDs such as tobacco use, hyperlipidaemia, and hypertension, but no countries have successfully reversed the increasing trends in diabetes prevalence and mortality from diabetes. This situation represents a massive global health failure, since type 2 diabetes is largely preventable with lifestyle modification and cost-effective treatments exist for both type 2 and type 1 diabetes.  Type 1 diabetes is of particular concern, since it is fatal in the absence of insulin treatment.
Tilly Alcayna, Vincenzo Bollettino, Lea Manzanero, and Patrick Vinck. 6/2019. Perceptions of Vulnerability, Preparedness, Assistance, and Barriers: Regional Infographics, the Philippines.Abstract

This report provides a regional breakdown of household perceptions and self-reported activities on several key questions related to disaster preparedness and recovery in the Philippines. These are: who and what is vulnerable? What preparedness activities have households undertaken? What assistance have households received and what helped them recover the most? What are the barriers?

The report is intended to be used in conjunction with the full report “Perceptions of Disaster Resilience and Preparedness in the Philippines” (2018), which explores perceptions on a wider variety of disaster related issues in greater detail. Data for both reports were derived from a nationwide, household-level survey of randomly selected adults aged 18 years old and above, representing all of Philippines economic strata, conducted in 2017.

Emmanuel Tronc, Rob Grace, and Anaïde Nahikian. 6/2019. “Realities and Myths of the “Triple Nexus”: Local Perspectives on Peacebuilding, Development, and Humanitarian Action in Mali”.Abstract

Despite decades of development programming for a country once upheld as a “model democracy” in Africa, Mali remains a country destabilized by extreme poverty; escalating violence and instability; and diminishing prospects for Malians’ futures in education, livelihoods, and stability. Even in light of an ongoing international presence and intervention in the country, and millions of dollars raised and spent each year on humanitarian programming, the persistent degradation of governance, livelihoods, and security continues.

What drives this state of affairs? How have international and regional actors contributed to sustaining a stagnating state at the expense of civilian populations and in the interest of preventing transnational Sahelian turmoil from expanding into the Maghreb and beyond to
European borders? What are the expectations and aspirations of local communities as they navigate the interconnected influences of extremist groups, government actors, and international military forces?

This paper examines these questions and offers reflections on various dynamics of the international response and the perceptions of local communities in this context. In particular, this analysis assesses the viability of the “triple nexus” concept, which aims—in protracted
and complex crises such as Mali—to forge an operational and policy alignment between international peacebuilding, development, and humanitarian efforts. The paper is based on a desk analysis of relevant literature, as well as over 130 interviews and consultations
undertaken with a variety of stakeholders, including government and non-state armed group representatives, civil society members, activists, journalists, humanitarians, analysts, diplomats, entrepreneurs, beneficiaries, displaced people, and students. The interviews were conducted in Mali, particularly in Bamako and in Central Mali, as well as abroad, between December 2018 and March 2019. The paper proceeds in four parts. Part I examines the key elements driving instability in this context. Part II focuses on international responses. Part III discusses the implications for the “triple nexus.” Part IV offers concluding remarks.

Philippa Boulle, Sylvia Kehlenbrink, James Smith, David Beran, and Kiran Jobanputra. 3/13/2019. “Challenges associated with providing diabetes care in humanitarian settings.” The Lancet, 7, 8, Pp. 648-656. Publisher's VersionAbstract
The humanitarian health landscape is gradually changing, partly as a result of the shift in global epidemiological trends and the rise of non-communicable diseases, including diabetes. Humanitarian actors are progressively incorporating care for diabetes into emergency medical response, but challenges abound. This Series paper discusses contemporary practical challenges associated with diabetes care in humanitarian contexts in low-income and middle-income countries, using the six building blocks of health systems described by WHO (information and research, service delivery, health workforce, medical products and technologies, governance, and financing) as a framework. Challenges include the scarcity of evidence on the management of diabetes and clinical guidelines adapted to humanitarian contexts; unavailability of core indicators for surveillance and monitoring systems; and restricted access to the medicines and diagnostics necessary for adequate clinical care. Policy and system frameworks do not routinely include diabetes and little funding is allocated for diabetes care in humanitarian crises. Humanitarian organisations are increasingly gaining experience delivering diabetes care, and interagency collaboration to coordinate, improve data collection, and analyse available programmes is in progress. However, the needs around all six WHO health system building blocks are immense, and much work needs to be done to improve diabetes care for crisis-affected populations.
Ronak B. Patel and Jay Chadhuri. 3/2019. “Revisiting the Sphere standards: comparing the revised Sphere standards to living standards in three urban informal settlements in Nairobi, Kenya.” Journal of International Humanitarian Action, 4, 6. Read PublicationAbstract
Humanitarian actors have long used the Sphere Handbook and its minimum standards to guide operational practice. The new revision attempts to update these standards partly to address urban crises that have challenged the humanitarian system. Yet, these indicators have never been based on a substantial body of evidence or data from the varied living standards found in cities or specifically informal settlements. This study aims to contextualize the Sphere standards for urban populations by comparing a sample of the revised key indicators to living standards in three urban informal settlements of Nairobi, Kenya, during a non-crisis period to examine their relevance and applicability, and discuss the implications.
Patrick Vinck, Phuong Pham, Kenedy Bungu, Juliet Bedford, and Eric Nilles. 3/2019. “Institutional trust and misinformation in the response to the 2018–19 Ebola outbreak in North Kivu, DR Congo: a population-based survey.” The Lancet Infectious Diseases, 19, 5, Pp. 529-536. Read PublicationAbstract
The current outbreak of Ebola in eastern DR Congo, beginning in 2018, emerged in a complex and violent political and security environment. Community-level prevention and outbreak control measures appear to be dependent on public trust in relevant authorities and information, but little scholarship has explored these issues. We aimed to investigate the role of trust and misinformation on individual preventive behaviours during an outbreak of Ebola virus disease (EVD).
Mihir Bhatt, Kelsey Gleason, and Ronak B. Patel. 1/2019. “Natural Hazards Governance in South Asia.” Oxford Research Encyclopedia of Natural Hazard Science. Read PublicationAbstract
South Asia is faced with a range of natural hazards, including floods, droughts, cyclones, earthquakes, landslides, and tsunamis. Rapid and unplanned urbanization, environmental degradation, climate change, and socioeconomic conditions are increasing citizens’ exposure to and risk from natural hazards and resulting in more frequent, intense, and costly disasters. Although governments and the international community are investing in disaster risk reduction, natural hazard governance in South Asian countries remain weak and often warrants a review when a major natural disaster strikes. Natural hazards governance is an emerging concept, and many countries in South Asia have a challenging hazard governance context.
Heather M Prendergast, Sara W Heinert, Timothy B Erickson, Trevonne M Thompson, and Terry L Vanden Hoek. 2019. “Evaluation of an Enhanced Peer Mentoring Program on Scholarly Productivity and Promotion in Academic Emergency Medicine: A Five-Year Review.” J Natl Med Assoc, 111, 6, Pp. 600-605.Abstract
OBJECTIVE: To design, implement, and evaluate the effectiveness of an enhanced peer mentoring program (EPMP) for faculty in emergency medicine aimed at overcoming traditional mentoring challenges. METHODS: Full time faculty (Clinical Instructor, Assistant, and Associate levels) were placed into peer groups (based upon their primary academic roles) led by senior faculty advisors at the Professor level. Peer groups met at least quarterly from 2012 to 2017. In lieu of a structured curriculum, session topics were informed by individual faculty surveys and peer group consensus. Areas of focus included work-life balance, prioritizing academic commitments, identification of mentors (both within and external to the department and university), networking opportunities, promotions goals, and career satisfaction. RESULTS: Effectiveness of the EPMP was evaluated by academic productivity and advancement over a 5- year period. A total of 22 faculty members participated in the program. There was an increase in promotions to the next academic level, from 3 promotions in the five years before the program to 7 promotions in the five years of the program. Total grant funding increased 3-fold from $500,000 to$1,706,479 from the first year to the last year of the evaluation period. CONCLUSIONS: This enhanced peer mentoring program was effective in mitigating many of the traditional mentoring challenges faced by faculty in academia and was successful in improving both academic productivity and advancement.
2018
Emmanuel Tronc and Anaïde Nahikian. 12/2018. Fragile Future: The human cost of conflict in Afghanistan. Read PublicationAbstract
This context analysis examines the humanitarian, political, societal, and economic dimensions that make the protracted conflict in Afghanistan intractable and precarious for civilian populations. The report is based on field visits to numerous regions in Afghanistan in July 2018 — which included interviews and consultations with a variety of actors, including political stakeholders, humanitarian agencies, and populations affected by conflict — as well as a review of recent and relevant literature. The purpose of this analysis is to (1) provide a current assessment of the conflict, drawing from field interviews and an in- depth assemblage of various reports and resources, (2) examine the interconnected and interdependent interests fueling the conflict, and (3) suggest that if these dynamics persist in the way they have for decades, recent elections and peace talks will represent yet another setback for Afghan communities and a peaceful future for the country.
Ronak B. Patel. 12/2018. “Precision Health in Disaster Medicine and Global Public Health.” Prehospital and Disaster Medicine, 33, 6, Pp. 565 - 566. Read PublicationAbstract
Current debates about precision medicine take different perspectives on its relevance and value in global health. The term has not yet been applied to disaster medicine or humanitarian health, but it may hold significant value. An interpretation of the term for global public health and disaster medicine is presented here for application to vulnerable populations. Embracing the term may drive more efficient use and targeting of limited resources while encouraging innovation and adopting the new approaches advocated in current humanitarian discourse.
Emmanuel Tronc, Rob Grace, and Anaïde Nahikian. 11/2018. Humanitarian Access Obstruction in Somalia: Externally Imposed and Self-Inflicted Dimensions . Read PublicationAbstract

Access obstruction in conflict settings has emerged as a critical operational and policy concern across the humanitarian sector, but there remains a dearth of analysis regarding the ways in which humanitarian organizations perpetuate self-inflicted access obstacles. Drawing on qualitative interviews conducted with local and international actors negotiating frontline humanitarian access in Somalia, this paper will examine the ways in which this context elucidates this phenomenon. Toward this end, this paper examines two dimensions of humanitarian access obstruction in this context. The first set of dynamics consists of externally imposed obstacles that stem from governmental actors, Al-Shabaab, access "gatekeepers" motivated by financial gain, and the insecure nature of the environment. The second set of dynamics consists of self-inflicted dimensions of access obstruction that emanate from decisions that international humanitarian organizations (IHOs) have made at the strategic or policy level. These issues include the physical "bunkerization" of IHOs, programmatic shortcomings, the discounting of local humanitarian actors' agency, and the ways that IHOs exhibit programmatic partiality in response to donors' interests and counterterrorism legislation. Through examining these issues, this paper highlights fact that, although the discourse on humanitarian access obstruction tends to emphasize difficulties arising from externally imposed obstacles, it is also important to interrogate the value and methods of humanitarian programming itself.

Program Resilient on Communities. 9/2018. Cagayan Valley Region: Household Preparedness.Abstract
Typhoon Ompong (Mangkhut) has had a major impact on the north of the Philippines damaging in excess of 76,000 homes in Cagayan Province (Region II Cagayan Valley) and completing destroying more than 10,000 homes there. The Philippines government and many national and international non-governmental organizations (NGOs) will be involved in the response. To help tailor the response it is useful to know what the level of preparedness for disaster was in Cagayan Valley Province before the storm hit.
The following statistics, compiled by the Harvard Humanitarian Initiative, were gathered between March and April of 2017.
Program Resilient on Communities. 9/2018. Cordillera Administrative Region: Household Preparedness.Abstract
Typhoon Ompong (Mangkhut) has had a major impact on the north of the Philippines displacing more than 50,000 people in Cordillera Administrative Region (CAR) and resulting in over PhP 14 billion in agriculatural damages (equivalent to approx. USD 270 million). The Philippines government and many national and international non-governmental organizations (NGOs) will be involved in the response. To help tailor the response it is useful to know what the level of preparedness for disaster was in Cordillera Administrative Region before the storm hit. The following statistics, compiled by the Harvard Humanitarian Initiative, were gathered between March and April of 2017.