Attila J. Hertelendy, Gregory R. Ciottone, Cheryl L. Mitchell, Jennifer Gutberg, and Frederick M. Burkle Jr. 8/2020. “Crisis Standards of Care in a Pandemic: Navigating the Ethical, Clinical, Psychological, and Policy-making Maelstrom.” International Journal for Quality in Health Care.Abstract

The COVID-19 pandemic has caused clinicians at the frontlines to confront difficult decisions regarding resource allocation, treatment options, and ultimately the life-saving measures that must be taken at the point of care. This article addresses the importance of enacting Crisis Standards of Care (CSC) as a policy mechanism to facilitate the shift to population-based medicine. In times of emergencies and crises such as this pandemic, the enactment of CSC enables concrete decisions to be made by governments relating to supply chains, resource allocation, and provision of care to maximize societal benefit. This shift from an individual to a population-based societal focus has profound consequences on how clinical decisions are made at the point of care. Failing to enact CSC may have psychological impacts for healthcare providers particularly related to moral distress, through an inability to fully enact individual beliefs (individually-focused clinical decisions) which form their moral compass.

Amir Khorram-Manesh, Eric Carlström, Attila J. Hertelendy, Krzysztof Goniewicz, Carter B. Casady, and Frederick M. Burkle Jr. 8/2020. “Does the Prosperity of a Country Play a Role in COVID-19 Outcomes?” Disaster Medicine and Public Health Preparedness.Abstract

Objective: This study aims to clarify the association between prosperity and novel coronavirus disease 2019 outcomes and its impact on the future management of pandemics.

Methods: This study is an observational study using information from two online registries. The numbers of infected individuals and deaths and the prosperity rank of each country were obtained from and the Legatum Institute’s Prosperity Index, respectively.

Results: There is a combination of countries with high and low prosperity on the list of coronavirus disease 2019 infected countries. The risk of the virus pandemic seems to be more extensive in countries with high prosperity. A Spearman’s rho test confirmed a significant correlation between prosperity, the number of coronavirus disease 2019 cases, and the number of deaths at the 99% level.

Conclusion: New emerging pandemics affect all nations. In order to increase the likelihood of successfully managing future events, it is important to consider pre-existing health security, valid population-based management approaches, medical decision-making, communication, continuous assessment, triage, treatment, early and complete physical distancing strategies, and logistics. These elements cannot be taught on-site and on occasion. There is a need for innovative and regular educational activities for all stakeholders committed to safeguarding our future defense systems concerning diagnostic, protection, treatment, and rehabilitation in pandemics as well as other emergencies.

Alan Parnell, Krzysztof Goniewicz, Amir Khorram-Manesh, Frederick M. Burkle Jr., Ahmed Al-Wathinani, and Attila J. Hertelendy. 8/2020. “COVID-19 a health reform catalyst? -Analyzing single-payer options in the U.S.: Considering economic values, recent proposals, and existing models from abroad.” Journal of Hospital Administration.Abstract

The United States has continued to face severe health coverage and spending challenges that have been attributed to a fragmented multi-payer and fee-for-service delivery system which has become even more exposed by the COVID-19 pandemic. Legislators and healthcare professionals have tried to answer the challenges faced by the U.S. health system through the introduction of several state and federal proposals for a "Medicare-for-all" like system, which have failed to be adopted likely due to the lack of consideration for free-market economic values. Looking to existing models abroad can provide the U.S. with different ways to understand how to achieve the benefits of single-payer models with universal coverage while maintaining the integrity of free-market values. The health systems in wealthy, industrialized countries are closely referenced in this article because of the variation of methods in which each achieves a single-payer/universal coverage model as well as the contrast in their health outcomes compared to that of the U.S. The biggest considerations for any reform effort to achieve an efficient single-payer system with universal coverage is the maintenance of private health insurers and the degree to which expanded government influence would be accepted. The future state of health care remains uncertain and unstable as a result of the COVID-19 pandemic, therefore a window of opportunity exists now for leveraging this uncertainty to achieve reform.

Frederick M. Burkle Jr. 7/2020. Robert Fox Interview with Frederick M. Burkle on Population-based Triage Management.Abstract
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.
Krzysztof Goniewicz, Beata Osiak, Witold Pawłowski, Robert Czerski, Frederick M. Burkle Jr., Dorota Lasota, and Mariusz Goniewicz. 7/2020. “Bioterrorism Preparedness and Response in Poland: Prevention, Surveillance, and Mitigation Planning.” Disaster Medicine and Public Health Preparedness.Abstract

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.

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.

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. 

frederick m burkle

Publication Release: Global Public Health Database Support to Pandemic Management

March 29, 2021

HHI is proud to share these two recent publications from Frederick M. Burkle, Jr., MD, MPH, DTM, FAAP, FACEP, former Senior Fellow and Scientist at HHI for over 17 years.

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

Read more about Publication Release: Global Public Health Database Support to Pandemic Management
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, 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.

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.

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.
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.
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.
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.”