One of the greatest challenges of the COVID-19 pandemic has been the fact it is a new disease and the first information about its pathology and epidemiology was collected as the outbreak was emerging. Although the virus is related to other coronaviruses that cause human disease, it is proving different in how it spreads and its clinical manifestations. The initial COVID-19 data that was collected in China during the winter of 2019-20 indicated transmission was attributable to symptomatic patients. As the pandemic grew and more data was collected, however, additional data suggested some patients did not display symptoms and therefore transmitted the disease unknowingly.

The change in the U.S. Centers for Disease Control and Prevention public health guidance is the result of this new data. Unlike the early stages of the pandemic when the recommendation was to mask patients only if they exhibited symptoms, the current guidance is for everyone who can tolerate a mask to wear one when in close proximity (less than six feet separation) to others. The new guidance was issued to reduce the transmission from asymptomatic patients, who may represent as much as 25 percent of those who are infected with SARS CoV-2.

As the pandemic continues to grow, there may be other changes in health recommendations for the public. The assessment and analysis of new data improves the public health response and reduces risk of infection for everyone.

Since the beginning of the twenty-first century there have been three outbreaks of a novel coronavirus disease in humans that significantly affected human health. Severe acute respiratory syndrome (SARS) emerged in China in 2002, Middle East respiratory syndrome (MERS) emerged in Saudi Arabia in 2012, and COVID-19 emerged in China in December 2019. In each outbreak, the coronavirus pathogen originated in a bat species and the disease “jumped” to humans via a second, intermediate animal host. The disease was initially transmitted by an interaction between a human and an infected animal and subsequently spread by human-to-human contact. Curtailing bat interactions with humans and other animals that are around humans would reduce the probability of harmful infectious disease outbreaks.

Some human-wildlife interactions are attributable to the loss habitat to economic development or demand for wildlife species as pets or sources of consumer products. The current coronavirus outbreak was traced to a live animal market where numerous species were bought and sold. To reduce human outbreaks from zoonotic diseases, humans must re-think how we interact with wildlife and encroach on their habitats.

One change humans can make is to not merchandise wild animals as pets or food sources. Wild animals live in different ecological systems than humans and have evolved to co-exist with a great diversity of bacteria, parasites, viruses, and other microbes that cause disease in humans. When a diverse group of wildlife are confined in close proximity, as in a marketplace, it increases the possibility of the introduction of a novel pathogen to humans. It also increases the possibility that a novel pathogen, especially a virus, could emerge due to evolutionary pressures as pathogens circulate among diverse species. For example, the coronavirus responsible for the 2002 SARS outbreak is believed to have come from a masked palm civet which acquired it from a bat.

A second change humans can make is to re-think how we encroach on wildlife habitats. One approach is to reduce the probability of human wildlife interactions by preserving adequate habitat areas or locating  human activities  away from critical feeding and nursery areas. Bats, as a species, sustain numerous virus types. Many of the infectious diseases that emerged since 1976, to include Ebola, Nipah, Hendra, SARS and MERS, originated in bats. At the same time, bats perform a variety of important functions that include pollination of many economically important plants as well as pest control of numerous insects. Bats are an important component of the ecological web and declines in bat populations could have significant consequences in both tropical and grassland environments.

The rate of the emergence of novel diseases, especially novel virus diseases, has accelerated in the last 50 years. Many of these diseases originated in various bat species. The maintenance of healthy bat populations, however, is necessary for pollination and pest control. Accommodation and preservation of bat habitats and removal of bats and other wildlife from crowded live animal markets could reduce the interactions between bats and people and minimize the emergence of harmful infectious diseases.

The COVID-19 virus has spread widely, both inside China and to the rest of the world. One possible transmission pathway that should be considered as part of the ongoing epidemiological investigation is the clandestine movement of wildlife and people across international borders.

Illicit international wildlife trade has been documented to occur and China is actively involved in the sale of wildlife in its live animal markets. Other coronavirus outbreaks, such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) were traced to a wildlife source when those diseases “jumped” to infect humans. A second possibility is the undocumented movement of persons across borders through human trafficking, the illicit drug trade, or other criminal activity. Human trafficking is recognized as a serious problem with many victims being trafficked to provide labor. The illicit drug trade and trade in other controlled products continues to occur because it is highly profitable.

COVID-19 infection has become a significant issue of international concern, both due to its impact on public health as well as on international economics. Investigating how the virus is moving from its source in China should include all possibilities because a thorough understanding of transmission dynamics is essential to controlling the disease.

The exposure to a novel coronavirus in Wuhan, China triggered an outbreak of human disease during December 2019. As of February 10, 2020 there were over 40,000 confirmed cases with over 900 deaths.[i]Genetic sequencing of the novel coronavirus shows it is related to both the severe acute respiratory syndrome (SARS) virus and the Middle East respiratory syndrome (MERS) virus,[ii]which caused human outbreaks in China during 2002 and in the Middle East during 2012. All three coronaviruses have a zoonotic origin. Coronaviruses exist in a variety of wildlife species and the current outbreak is believed to have jumped from animals to humans. In light of the current situation and a history of other coronavirus diseases jumping to humans, the Chinese government ordered the temporary closure of live wildlife markets as a disease control measure. Such markets pose an identifiable risk to human health and the permanent closure of live wildlife markets should be considered.

Close proximity interactions between non-domestic animals of varying species in live markets pose significant human health risks. They provide an opportunity for the spread of infectious diseases between the caged animals and humans who visit the markets. Among the post-outbreak findings from the SARS and MERS outbreaks was that the viruses adapted to humans once it spread within communities. Although much remains uncertain about the current coronavirus outbreak, previous experience suggests a similar human adaptation is possible. Additionally, the fact that the outbreak emerged in a densely populated city such as Wuhan and has spread among people who have not had direct contact with the live wildlife markets raises concerns about its epidemic potential.

Placing several Chinese cities under quarantine, as the government has ordered, could reduce the spread of the novel coronavirus disease outside the most severely affected areas. However, the effectiveness of a quarantine as a control measure is questionable as time passes for logistic (supporting the quarantined population with food and other essential goods) and social/political (the willingness of the population to suspend their usual activities) reasons.

Although it may too late to affect the course of the current outbreak, the permanent closure of live wildlife markets should be considered as a public health policy intervention. Eliminating close interactions among wildlife species and the subsequent exposure of the animals to humans could reduce the risk of another novel disease emerging. History suggests there may be other coronavirus outbreaks with similar characteristics and consequences in the future if no preventive action is taken.

[i]Case counts provided by World Health Organization, available at www.who.inton on February 10, 2020.

[ii]Roujian Lu and others, “Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding,” The Lancet, Published online January 29, 2020 https://doi.org/10.1016/S0140-6736(20)30251-8  

A recent surge in the number of measles cases in the United States and elsewhere along with the findings of two scientific studies that reported measles infection reduces the immune response to other diseases points to previously unrecognized public health vulnerabilities for those who have not been vaccinated for measles. The findings, which were described in the fall of 2019[i],[ii], show the pathology of measles infection causes a reduction in the body’s ability to mount an effective immune defense against a disease for which the person has pre-existing immunity (either from infection recovery or successful vaccination) and it also reduces the body’s ability to defend against an infectious disease that is new. Measles one of the most highly infectious viral diseases and has a major impact on the health of children. This circumstance calls for a renewed effort to prevent the spread of measles through vaccination and a robust public health contingency plan to respond the emerging outbreaks.

Although measles was largely eliminated in the United States in 2000, declining vaccination rates encouraged by a campaign to falsely associate measles vaccination with a coincidental increase in autism spectrum diagnoses has led to an increase in measles infections, especially among children. Measles is a reportable disease, so surveillance for disease occurrence is a regulatory requirement and robust. What is less clear, however, are which communities are at greater risk for contracting the disease due to vaccine refusal. For example, communities of children may be based on where they attend daycare or school and may be different than the geographic neighborhoods where they live. This is why contact tracing must be especially precise for both geospatial and temporal data. In addition, the reasons for children not receiving the measles vaccination are not always due to lack of access to healthcare or cost but may be the result of decisions by parents or caregivers to withhold the vaccine. This is why it is useful to ascertain the vaccination status of persons in the community with a high degree of certainty as part of investigating an ongoing outbreak. The fact that measles can only be controlled by maintenance of a vaccination rate greater than 90% leaves communities vulnerable. Other infectious diseases, including those associated with children, could also become more problematic as previously acquired immunity from recovery or vaccination is degraded as a consequence of catching measles.

Measles is not a benign disease. Although children who have become infected generally recover without any long-term consequences, the percentage of children who experience life threatening symptoms such as pneumonia or encephalitis, or death is not insignificant. Childhood measles vaccination is essential for the prevention of measles outbreaks in the United States, serious complications associated with measles infection, as well as other infectious diseases.

[i] V. N. Petrova, B. Sawatsky, A. X. Han, B. M. Laksono, L. Walz, E. Parker, K. Pieper, C. A. Anderson, R. D. de Vries, A. Lanzavecchia, P. Kellam, V. von Messling, R. L. de Swart, C. A. Russell, Incomplete genetic reconstitution of B cell pools contributes to prolonged immunosuppression after measles. Sci. Immunol. 4, eaay6125 (2019

[ii]Choy, Mark S. Wilson, H. Benjamin Larman, Ashley N. Nelson, Diane E. Griffin, Rik L. de Swart and Stephen J. Elledge Michael J. Mina, Tomasz Kula, Yumei Leng, Mamie Li, Rory D. de Vries, Mikael Knip, Heli Siljander, Marian Rewers, David F., Measles virus infection diminishes preexisting antibodies that offer protection from other pathogens. DOI: 10.1126/science.aay6485 (6465), 599-606.366Science 

Violence and associated risk factors

Many risk factors are relevant in assessing the potential for violent acts. Information on previous violent behavior and substance abuse should be considered.  

The United States experienced numerous mass shootings during 2019 and these incidents have called into question the linkage between mental illness and homicidal violent behavior. A U.S. Government report[i]states mental illness, by itself, does not increase the probability someone will commit violence against others. Patients with mental illness are, in fact, are more likely to be victimized by violence than the general population.[ii]When mental illness occurs simultaneously with other risk factors such as substance abuse, however, there may an increase in violent behavior.[iii]Given this assessment, a more comprehensive mental health screening during the background check process for the purchase of firearms could reduce injuries and deaths from gun violence if such screenings address other risk factors for violence. Substance abuse, and characteristics such as poor impulse control, previous violent behavior, bullying, demonstrated disregard for the welfare of others, aggressive driving, and fire setting are relevant in assessing if it is safe to sell a gun to a prospective purchaser. 

Epidemiological analysis is a useful tool for quantifying health risks. It is data driven and can provide an unbiased clinical assessment. Epidemiological data provides the basis for making diagnosis and treatment decisions and also identifies how mental illness and other violence risk factors increase the probability of violent behavior. At the same time, however, there are violence associated risk factors and behaviors that may never be observed by mental health professionals because they do not necessarily trigger a formal mental health evaluation or criminal investigation. For example, animal cruelty behaviors have been retrospectively correlated to later incidents of violence. Unless the animal cruelty incident resulted in a formal investigation, there is no mechanism to capture such information for the background check process. 

The challenge of improving the background check process is to incorporate more data that is relevant to a risk assessment for future violent behavior. Documented evidence of antisocial behavior associated with violence could exist in a variety of databases including driving records, local social service agency records, school records, or medical records. Such information as well as Information collected by law enforcement agencies from online sources relating to threatened use of violence, such as racial animus, should be made available to the background check system for review before a gun purchase license is granted. 

[i] U.S. Department of Health and Human Services, “Mental Health Myths and Facts,” August 29, 2017 available at https://www.mentalhealth.gov/basics/mental-health-myths-facts on September 22, 2019.

[ii] U.S. Department of Health and Human Services, “Mental Health Myths and Facts,” August 29, 2017 available at https://www.mentalhealth.gov/basics/mental-health-myths-facts on September 22, 2019

[iii]U.S. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention, “The Social-Ecological Model: A Framework for Prevention, available at https://www.cdc.gov/violenceprevention/publichealthissue/social-ecologicalmodel.html on September 23, 2019.

It is a human inclination to focus on the urgent, that which presents an immediate problem, over the important, that which causes permanent and detrimental long-term consequences. While behaviors that focus on immediate threats have served humans well by enabling us to survive, it is essential now to analyze and consider long-term repercussions of delaying effective actions to ensure survival in the face of climate change. This future threat is important because the damage is cumulative and largely irreversible. One unyielding truth is that the planet has a closed ecosystem and everyone will be affected by climate change. The U.S. has yet to undertake all of those policy changes that will reduce global warming. The time to reverse climate change has already passed and we are rapidly approaching the deadline when mitigating its worst outcomes is still possible. Health experts have long understood that the key to optimal health is prevention of disease. Preventing future consequences of climate change, like disease prevention, will lower the costs associated with responding to a long-term environmental crisis.

According to the United Nations Intergovernmental Panel on Climate Change, the injurious effects of global warming include ocean level rise and inundation of coastal communities. Southern Florida is already experiencing this phenomenon. Seasonal hurricanes will become more intense and dangerous. Productive farmland will become less productive due to changes in rainfall and temperature. Wildlife species that provide important ecological services such as plant pollination will leave their current habitats because of deteriorating environmental conditions and increasing exposure to hazards such as disease and predation. Additionally, current patterns of infectious disease spread will change as human disease vectors overtake new areas and become established. The U.S. government Global Change Research Program reported the failure to alter activities causing climate change will result in damage to the economy, local communities, and domestic infrastructure.

The warming of the oceans is expected to increase the amount of atmospheric carbon dioxide and reduce the amount of dissolved oxygen in seawater. As the temperature of the ocean increases, dissolved gases escape into the atmosphere. Carbon dioxide is a greenhouse gas and an increased atmospheric concentration traps heat and increases global warming. As oxygen escapes into the atmosphere, it decreases the amount available to marine life and can be expected to affect fisheries and food security. Ocean warming also plays a role in the development of toxic algae blooms, such as the ones that occurred in Florida during the summer of 2018 that killed marine life, caused economic losses, and caused illness in humans. The worldwide inventory of the elemental building blocks of the air, water, and soil that exist now are what future generations will have available. 

A related corollary is that the waste products we discard remain in the environment unless they are chemically broken down by natural or artificial chemical processes. Climate change also can be an issue in the effort to contain dangerous refuse that has been insufficiently sequestered underground. One of the lessons from the hurricanes that struck the southern Atlantic coast of the U.S. during 2018 was the holding ponds of toxic chemicals from industrial mining are not a permanent solution to their disposal. When the storms passed and flooded the holding ponds, they overflowed and sent the waste products into nearby rivers and streams, contaminating the water supplies of downstream communities. Freshwater is but a small percentage of all water that exists on the earth and the effective recycling of this critical resource is essential to human and other terrestrial life forms. Natural processes have provided sufficient freshwater resources to maintain life for hundreds of thousands of years. However, if these supplies are diminished by the effects of climate change, human life will be directly threatened. It is already the case that national security experts believe a major source of conflict in the future will be competition for water and efforts by states to guarantee access to that essential resource. Human survival is truly dependent on wise husbanding of worldwide water resources.

Runaway climate change will alter the natural world. Science projects many of these changes will be catastrophic to the health and well-being of humans and other species. The failure to take corrective action to mitigate the effects will cause harmful consequences for all of us. 

Health is a quintessential element of national security. It is critical to a strong military force, which is the traditional notion of national security. It is also essential to other elements of national security such as the economy, the society, and political equilibrium (specifically the narrowing of health disparities). The simple fact is that if the country’s population is not healthy, it has downstream effects on the entire country.

Recent proposals to further reduce nutrition support for the poor can pose a long-term threat to security because it diminishes the ability of about 13 percent of the U.S. population to achieve optimal health and participate in the various activities that make the United States a strong and secure country. Inadequate nutrition can have an immediate effect on the ability of an adult to work, over time it has detrimental effects on physical and cognitive development in children. Inadequate nutrition in adults and children compromises immune function and increases susceptibility to infectious disease and can play a role in the development and progression of chronic disease. Ill-heath is a significant factor in lost labor productivity and decreased economic production and a significant direct cost to the economy. 

Production that does not occur due to labor force non-participation ultimately manifests in decreased economic output and lower government revenue, which will have a direct impact on government funding to provide public services such as internal and external security, education, transportation and electricity infrastructure, and healthcare. 

The Constitution requires the federal government to conduct a census every ten years. Among the reasons are to realign congressional representation in the U.S. House of Representatives, apportion funds to pay for federal government functions and infrastructure, and to provide baseline population data for disaster and crisis response.[i] The decennial census is designed to count every person living in the United States without regard to citizenship status. These counts are updated regularly with data collected from the American Community Survey, a statistical estimate of population changes from year to year. All of the above mentioned uses of the census data are critical but none have the same immediate impact as having accurate data when the federal government is asked to respond to a natural disaster or a health emergency. Without accurate data on the number and location of people who are affected by an emergency, the crisis cannot be addressed effectively. Any policy that may encourage people not to respond to the census questions is inconsistent with the requirement specified in the U.S. Constitution and the best interest of the people of the United States.

When a natural disaster strikes a community, immediate assistance is required to save lives and protect property. First responders must have accurate information about how many people could be affected and where they live to do their jobs. A census undercount could result in insufficient resource deployment, leaving some people without appropriate assistance. A public health crisis, such as a severe influenza outbreak, could result in some affected people not receiving treatment if public health responders do not know the total number of people who are at risk of becoming sick due to inaccurate or incomplete census information. Such a circumstance would negatively affect efforts to control the outbreak and limit illness and mortality. Even during an average year, more than 30,000 people die from influenza infection, so the potential for harm is significant. Citizenship status is not important to responding to a natural disaster or controlling a disease outbreak; what authorities really need to know is how many people may need help.

A census undercount has numerous negative effects, maldistribution of federal resources for representation, infrastructure, and social programs as well as an inadequate response to natural disasters and public health crises. Anything that impedes a full count of every person living within the United States will harm the entire country. Every possible effort should be made to accurately count each person resident in the United States and universal participation is critical.

[i]See U.S. Bureau of the Census, https://www.census.gov/about/what.html 

Revitalizing infrastructure remains an important imperative for the federal government. Legislation to support the rehabilitation and improvement in transportation, power generation, telecommunications and other nationwide systems could facilitate economic growth and improve population welfare. Although health infrastructure does not receive as much attention in discussion of national infrastructure priorities, it is an essential component that will support the national economy and also improve lives. Any policy proposal to fund infrastructure improvements should include health infrastructure, especially in the areas of workforce, data systems, and crisis response; these areas were identified by a federal study as being critical parts of the national health infrastructure.[i]

While the United States spends about one sixth of its GDP on health related expenses, it still does not reap the same level of tangible benefits as other peer developed countries that spend much less on a per capita basis. Additionally, the emergence of climate change and exotic zoonotic diseases challenges to U.S. heath infrastructure in novel ways. A modern U.S. health infrastructure will need to develop capabilities across human and animal health to optimize benefits to the U.S. economy and residents.

Currently, there are workforce shortages in a variety of health fields including physicians[ii]and veterinarians[iii]. As the U.S. population ages, there is increased demands for health services. Also, for reasons that are not yet clear, the health status of younger Americans is worse that it was for previous generations of Americans at the same age and may be an additional cause of increased health service demand. [iv]Climate change has resulted in changes in disease patterns among animal populations. Previously unknown pathogens will likely increase the demand for veterinary clinical services including animal disease surveillance and outbreak management. Further integration of human and animal health, or “one health” infrastructure, will be essential for building additional health capacity.

Modernization and improvements of health systems, particularly in the areas of telecommunications and cybersecurity will support the needs of health infrastructure by improving medical record keeping and information access when patients are treated. Disease patterns will be identified and outbreak response can be occur more quickly. The recent approval for the merger of CVS Pharmacy and Aetna health insurance suggest a shift from large medical practices to retail health settings for routine healthcare. If stand-alone clinics become an increasingly popular source of preventive and well-being health services, more reliable and comprehensive access to individual medical records will facilitate optimal care. 

Effective crisis response to health emergencies requires support from other critical infrastructures because the immediate requirement is to deploy resources as quickly as possible for rescue and recovery. Depending on the nature of the health emergency, such as hurricane response for example, rescue workers may need to get to disaster areas quickly to restore basic health services. Affected health infrastructure may require transportation, telecommunications, and electrical power systems as well as possibly erecting temporary clinical facilities to resume operations. A different health crisis may require specialized clinical isolation and treatment facilities be created to contain a widespread infectious disease outbreak. To the extent that a rapid and efficient response will minimize deaths and more severe health consequences, collaborations between various infrastructure stakeholders would ideally include exercise for a variety of health crisis scenarios.

Health systems and infrastructure are an important area of the overall U.S. infrastructure and must be an integral part of planning nationwide updates and modernization. 

[i]See Healthy People 2020, Public Health Infrastructure, https://www.healthypeople.gov/2020/topics-objectives/topic/public-health-infrastructure, accessed on June 9, 2019.

[ii]Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Physicians and Surgeons,

on the Internet at https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm (visited June 06, 2019). See U.S. Department of Health and Human Services, Health Resources and Services Administration, https://data.hrsa.gov/topics/health-workforce/shortage-areas, accessed on June 9, 2019.

[iii]See Journal of the American Veterinary Medical Association, https://www.avma.org/News/JAVMANews/Pages/181215e.aspx?PF=1, accessed on June 9, 2019

[iv] See Blue Cross Blue Shield, “The Health of Millennials,” https://www.bcbs.com/the-health-of-america/reports/the-health-of-millennials accessed June 9, 2019.

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