As the United States approaches fall 2020 it faces four major crises (COVID-19, the precipitous drop in GDP, western wildfires, and numerous hurricanes in the southeast) in addition to the impact of seasonal flu. The intersection of these events and the impact of housing loss will strain the ability to curb further spread of COVID-19. One model predicts an additional 100,000 deaths by the end of 2020, which would raise the death toll to over 300,000 since the beginning of 2020. The key to controlling the pandemic before an effective vaccine is available is minimizing COVID-19 transmission. The keys to mitigating the effects of these multiple disasters is providing economic support to those affected by the economic downturn, along with measures to re-house those who have been displaced by the hurricanes and wildfires in a way that limits both COVID-19 and flu infections. The key to reviving the economy is to control the pandemic.
The economic downturn caused by COVID-19 has had wide ranging effects on health and limited the ability of many Americans to protect themselves from being infected. Many initially furloughed workers became unemployed when their employers were forced to shutter. The loss of income causes food insecurity, which has a direct impact on health and the ability to resist infections. Loss of housing or loss of utilities (such as water and electricity) which are essential for maintaining health and hygiene increases the risk of exposure to COVID-19 because people are forced to live in more crowded circumstances or they do not have the resources to maintain a clean and sanitary living environment. The loss of health insurance affects the medical management of chronic diseases and the wherewithal to seek healthcare for new illnesses, including COVID-19. The wildfires in California, Oregon, and Washington present similar challenges inasmuch as they also cause job losses and destroy housing, health facilities and other infrastructure. Media reports 5500 homes and businesses and 3.4 million acres have burned during 2020 in California alone. All three states will need to find temporary shelter that will also protect thousands of people from COVID-19. Destruction of homes will complicate responding to the housing crisis for displaced people because COVID-19 demands temporary housing that limits the number of persons living in close quarters. There must also be additional facilities to identify and isolate people who become infected until they recover and can return to their temporary homes
The 2020 hurricane season has been active, with serious storms affecting both the Gulf and Atlantic coasts. Damage to health facilities and other infrastructure has affected health resource availability for COVID response. Destruction of homes will require also responding to a housing crisis. The necessity of housing displaced people in small family groups will exacerbate the already difficult problem of providing temporary homes in the aftermath of hurricanes.
The ongoing COVID-19 pandemic shows no signs of slowing down; the number of cases in the United States now exceeds seven million as of September 29, 2020. Infection control has not been effective for several reasons: less than universal compliance with wearing face masks and social distancing recommendations, and re-opening of education institutions and some commercial activities for in-person interactions without strict adherence to physical separation precautions. The change of seasons will affect risk of respiratory disease transmission because people will spend more time indoors as it becomes colder in northern parts of the United States. The arrival of seasonal flu in autumn always raises concern about widespread transmission of respiratory disease and co-infection with COVID-19 is likely to have serious health consequences for anyone who becomes infected with both.
Once the spread of the coronavirus is brought under control by adherence to recommended public health measures, it will be possible to re-open many of the activities closed earlier in the year. While public health investments such as personal protective equipment and modifications to indoor environments to increase air exchange will be needed to protect people from continued circulation of the SARS CoV-2 virus, industrial facilities, schools, and other institutions which require in person interactions will be made safer for gatherings and some group activities can resume. Once an effective vaccine is developed and widely distributed, it will be possible to return to pre-COVID life and the downturn should abate.
Continuing research and analysis of clinical data shows there are significant long-term health consequences among COVID-19 survivors. These long-term consequences include lung damage, damage resulting from blood clots in the circulatory system and kidneys, and neurological and cognitive effects. These consequences have affected those with both asymptomatic and symptomatic infections. During the 2017-2018 flu season in the United States, there were an estimated 61,000 attributable deaths according to the U.S. Centers for Disease Control and Prevention. As of September 1, 2020 the number of confirmed COVID-19 cases in the United States was over six million. The combination of an ongoing COVID-19 pandemic and seasonal flu is expected to cause an increased burden of respiratory disease during late 2020 into mid-spring 2021. People who contract both COVID-19 and seasonal flu, and COVID-19 survivors who subsequently are infected with the flu, may be more vulnerable to severe flu outcomes because of lingering health consequences.
There are several measures that can reduce mortality risk from both COVID-19 and seasonal flu. First, increasing the availability of COVID-19 diagnostic testing would help quickly identify people who are infected with COVID-19 so they could be isolated and avoid becoming co-infected with flu. It would also help to reduce the spread of COVID-19 to persons who are susceptible to the flu. Second, more people should be encouraged to get the seasonal flu vaccination. Vaccination provides protection from becoming infected or severe disease. Numerous studies over many years demonstrate the efficacy of flu vaccine in reducing illness and death. Getting the flu after recovering from COVID-19 may make acute flu infection more severe for some people. Additionally, flu infection may also cause health effects that exacerbate the COVID-19 long-term consequences. Third, health authorities should prepare now to assure sufficient supplies of the antiviral drugs to treat patients who contract the flu. Given both flu and COVID-19 will be circulating at the same time, minimizing the effects of flu could reduce the risk of severe illness and death if there is simultaneous infection.
The SARS CoV-2 virus will continue to cause infections as long as there is no effective vaccine. Even if one or more vaccine candidates were to be gain regulatory approval for use, it would still take time to produce and distribute the more than 7 billion people on the planet. In the meantime, it is essential to take steps and reduce the burden of disease from COVID-19 and seasonal flu.
Two unexpected anomalies have emerged since early July 2020 with respect to the continuing COVID-19 pandemic. First, the emergence of 97,000 cases among children provided evidence children can become infected, though they may not exhibit serious symptoms of the disease. As we approach the fall and the resumption of primary and secondary education, this poses serious challenges for educators as they plan instruction for the upcoming academic year. Second, the surge in cases, especially in regions and less urban areas that had not seen significant numbers of people afflicted with COVID-19, shows smaller communities are as vulnerable to the spread of COVID-19 as the original outbreak hotspots on the east and west coasts. These two events are reasons why it is critical to expand testing and fully implement preventive measures in all communities to reduce the spread of disease. The management of the pandemic as the summer ends and we move toward the height of influenza season will profoundly affect how and if pre-pandemic levels of economic activity can be achieved in the near-term. It could also have an impact on the costs of the pandemic.
A sharp rise in cases and deaths has been noted recently, often in communities with limited resources and among populations who face significant health disparities and suffer disproportionately with serious illness. When the SARS CoV-2 virus first arrived in the United States in early 2020, the greater New York City region, Seattle, and large metropolitan areas of California were most immediately and severely affected. Once the virus spread to other large cities such as Chicago, state governments began to implement stay-at-home orders and closed all but essential businesses; schools were also closed. This had the effect of reducing the spread of disease, but also precipitated a severe economic decline. By the early summer, the rapid rate of COVID-19 spread had abated in the early hot spots and those areas which had not seen a large number cases began loosening restrictions and re-opening businesses. The two months in which the restrictions limited non-essential commerce created a “pent up” demand for a return to more normal economic and social activities. The arrival of warmer weather and the traditional vacation travel season led to many people to abandon precautionary measures. The surge in the number of new COVID-19 cases began shortly after the Memorial Day holiday and accelerated through the Independence Day holiday. Retrospective analysis of COVID-19 spread since the early summer indicates much of the spread can be traced to clusters of people interacting in close proximity. Anecdotally, there are numerous reports and photographs of crowded events preceding a local spike in cases. Additionally, ongoing research on the pathology of SARS-CoV-2 infection found that a large number of persons, both adults and children, have asymptomatic infections. This complicates the identification of infected people and they unknowingly infect others. Some communities have re-imposed some restrictions in an effort to regain control over COVID-19 spread. However, with more than five million confirmed infections and likely a large number of asymptomatic ones, it will be extremely challenging to limit further spread.
The combination of child susceptibility and the absence of symptoms during infection could drive a significant surge of cases after schools re-open. Without effective diagnostic testing, it is impossible to know if students are infected and at risk of spreading the disease. While the children may not be sick enough to require treatment or hospitalization, without continuous surveillance testing, these children could become silent spreaders of disease to older family members who are more likely to suffer severe effects of COVID-19 disease. The essential elements of controlling the disease are identifying cases and preventing those cases from spreading it to others in all school settings.
Another significant related challenge of SARS C0V-2 virus infection is long-term effects are not yet well understood. The eight months that COVID-19 has been recognized is not long enough to collect sufficient data for an accurate assessment. However, anecdotal reporting provides important evidence that the long-term effects are significant. Among adults, prolonged lung damage, heart, kidney and neurological damage from blood clotting, and cognitive decline were observed. In some instances, these effects were observed in patients who did not have severe acute disease. Children who experience a Kawasaki-like inflammatory syndrome during the acute phase of COVID-19 infection may also experience long-term effects. As more data is gathered from COVID-19 survivors, still other medical issues may be discovered. At a minimum, patients experiencing prolonged symptoms may be prevented from returning to their normal activities, thus causing economic losses and social consequences. In addition, those patients who experience post-infection cognitive or neurological symptoms will also incur additional medical and rehabilitation costs. The costs of long-term management of these effects could prove expensive. Again, the best strategy for reducing illness, death, and potential future lingering after-effects is identifying cases and preventing further disease spread.
Re-opening schools for in person instruction and businesses for pre-pandemic economic activity in the absence of effective disease transmission control measures would trigger a return to the crisis experienced during the early days of the pandemic. What is required to resume many pre-pandemic activities safely everywhere is to follow the public health recommendations of hand hygiene, masks, crowd avoidance, and social distancing and make the investments that will mitigate COVID-19 spread including physical barriers to block droplets, sufficient diagnostic and surveillance testing, effective contact tracing, and modifying interior ventilation to improve air exchange as required. It will not prevent all deaths, but it will reduce the massive toll of illness that has occurred during 2020 as well as the additional costs associated with addressing the long-term effects of disease. Some of these mitigation measures will also have the advantage of reducing the health consequences of seasonal influenza and other respiratory infections.
A clinical study comparing the level of COVID-19 virus RNA in children under five years old with other age cohorts using PCR (polymerase chain reaction, a method to quantify the amount of viral RNA present in a sample) found that the young children under five had significantly higher numbers of viral RNA than older children and adults.[i] While the study did not determine if there were also higher levels of live virus in this group, other research suggests a correlation between the level of viral RNA and live virus. Also, the only source of viral RNA would be the virus itself, so the presence of the viral RNA does indicate exposure to the virus.
These findings are important for the continuing efforts to control the spread of COVID-19, especially in day-care centers, schools, and households. Young children, though they may not become symptomatically ill, may still harbor the virus and spread it to older people. This is significant if the household is multigenerational or if there are older children present who could transmit the virus at school. In such cases, the contacts with people outside the household should be reduced as much as possible to reduce infection risk. It also indicates that mitigation strategies (hand hygiene, surface disinfection, physical distancing, wearing face masks, and isolation if disease symptoms are present) are especially essential for settings where young children congregate. Protecting the adults that take care of young children in day care or school settings should be a community priority and those workers should have access to the full complement of personal protective equipment including N95 masks, and protective garments.
As of July 31, the United States continues to lead the world in the number of COVID-19 cases with over 4.5 million and the number of deaths with over 150,000. Additionally, the number and rate of new infections in the United States continues to rise. Controlling the spread of COVID -19 is critical to the safe re-opening of the economy.
[i] Heald-Sargent T, Muller WJ, Zheng X, Rippe J, Patel AB, Kociolek LK. Age-Related Differences in Nasopharyngeal Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Levels in Patients With Mild to Moderate Coronavirus Disease 2019 (COVID-19). JAMA Pediatr. Published online July 30, 2020. doi:10.1001/jamapediatrics.2020.3651
During the seven day period ending on June 17, ten states reported a spike in the number of reported COVID-19 cases in the United States. These states were North Carolina, South Carolina, Georgia, Florida, Alabama, Wisconsin, Illinois, Texas, Arizona, and California. Six of these states: North Carolina, Georgia, Florida, Illinois, Texas, and California, have large populations of African Americans. African Americans Latinos, and indigenous Americans experience a variety of health disparities that have made the impact of COVID-19 much worse for them on a population basis than for Caucasians. While all of the reasons why these states have experienced significant increases in the number of COVID-19 cases are not known, increased interactions among people after various states reduced stay-at-home restrictions, and decreased adherence to social distancing and mask wearing are likely to have played a role. Additionally, clinical research indicates some disease transmission occurs when no symptoms are present, so people spread the virus without knowing they are infected. The current challenge is to reduce disease spread, especially among African Americans, and other people of color, who have been shown to be more vulnerable to severe disease. Data from the U.S. Department of Health and Human Services report 55.5 percent of non-Hispanic blacks in comparison to 75.4 percent of non-Hispanic Caucasians used private health insurance during 2017;[i]9.9 percent of non-Hispanic blacks in comparison to 5.9 percent of non-Hispanic Caucasians were uninsured.[ii]Access to health insurance and, by extension healthcare, is one of several significant health disparities that contribute to a higher rate of chronic disease among African Americans. Chronic diseases are associated with more severe COVID-19 outcomes. Similar disparities exist for other marginalized groups.
The SARS-CoV-2 virus will not be eliminated in the near-term. Even if a successful vaccine is developed it requires protection of more than 70 percent of the world’s population to eliminate the disease. Producing enough vaccine doses for more than seven billion people will likely cause bottlenecks which will take time to resolve; perhaps the most significant of these will be the limited vaccine production capacity. Universally applied mitigation strategies that should be implemented to minimize the adverse effects on disadvantaged communities include more diagnostic testing to identify cases and quarantine of newly infected persons to interrupt transmission within populations. Antibody testing in specific geographic areas is needed to determine and understand the how prevalent COVID-19 disease is in specific communities. Improved healthcare access is needed to reduce health conditions that adversely affect the course of disease and provide early treatment to limit health deterioration if infection occurs. Also, more personal protection equipment (PPE) is needed for all workers who have essential and public facing jobs that place them at greater risk for virus exposure.
In the absence of continuation of the strict lockdown measures that allowed the trajectory of the COVID-19 pandemic to be reduced, we can expect that the number of infected persons will continue to increase. While the lockdown prevented the U.S. health system from being overwhelmed, it did not alter the infectiousness of the virus and thus, it continues to spread. The maintenance of social distancing and mask wearing can curb virus exposure and transmission. These measures, especially in those areas having a spike in the number of cases, along with the mitigation strategies mentioned above, and research to find effective treatments and vaccines will improve outcomes for everyone.
[i]See: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=61
[ii] Op.cit at 1.
COVID-19 has sparked the most profound economic crisis unrelated to armed conflict since the 1918 influenza pandemic. Fortunately, there is now far more scientific understanding of disease dynamics to inform the best practices for returning to normal activity. Following are some important considerations for a return to the interactions that underpin the economy.
· Implementing comprehensive disease surveillance. This includes adequate clinical testing to provide an accurate knowledge of who and where newly infected persons are and tracing the contacts of confirmed cases. In the United States, this required level of testing has not been reached. Additionally, it is critical to know who has immunity by testing for antibodies. Anecdotal data suggests there is a significant percentage of infections that are not accompanied by symptoms of disease. Antibody tests are essential for anyone returning to a work situation that precludes the possibility of social distancing.
· Collecting and analyzing virus samples over time. This includes genetic analysis of samples both within communities as well as samples from distant places to provide an understanding of how the virus is mutating. The SARS CoV-2 is a pathogen that can mutate quickly and some mutations directly affect whether a recovered person can effectively fight a new exposure to the virus. This is the reason why health officials monitor new influenza virus strains every year. As with seasonal influenza, if the virus mutates in specific ways, it is possible to acquire a new infection even though one has suffered a previous infection.
· Analyzing clinical data to ascertain why certain characteristics predispose some people to more severe disease. Based on the case reporting, we know that African Americans, Hispanics, and those with pre-existing chronic diseases have much higher rates of death and severe illness than others. A comprehensive analysis of patient health status will help protect those who are most vulnerable to serious disease after exposure to COVID-19.
The consequences of the COVID-19 pandemic have caused more economic dislocation than any event other than war since the beginning of industrial age. However, a failure to thoughtfully and adequately plan for a return to economic production will ultimately be more costly in both lives and treasure.
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.
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
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.