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December 2018 update on Democratic Republic of Congo Ebola outbreak

The Ebola outbreak in Democratic Republic of Congo (DRC) continues and has spread to the large city of Butembo, as well as to Beni, an area beset by armed conflict. As of December 12, 2018, there are 515 confirmed/probable cases and 303 confirmed/probable deaths. Although DRC health officials have acted to limit the spread of the disease, constrained supplies of the experimental vaccine, technical and logistic challenges associated with the available treatments, and the breakdown of security in some affected areas complicate their ability to identify and treat new Ebola cases. This outbreak has now become the second largest Ebola outbreak since the disease was identified over forty years ago. The World Health Organization (WHO) and its partners continue their efforts to control its spread, but success will depend on being able to access Ebola affected communities and establish security, and engage community members with practices that respect cultural norms while promoting effective public health interventions. Notably, the WHO also reports DRC is simultaneously responding to outbreaks of cholera, measles, and monkeypox. 

One of the essential elements of an effective outbreak response is providing security to the affected area. Emergency responders need safe and unrestricted access to persons who are affected by the outbreak. Patients must have the freedom of movement to seek medical care at health facilities, patient’s homes, or wherever assistance can be provided. Patients and their families need to be confident that the only mission of medical personnel is to provide the best possible clinical care without a political agenda. Community information sharing about the disease is another important element of an effective outbreak response. One of the lessons learned from the 2012-2014 West Africa Ebola outbreak was that family members needed to be educated about the disease and engaged with the patient during treatment. Due to concerns about disease transmission during that outbreak, Ebola treatment units isolated patients from their families and, as a result, families removed patients from treatment or refused to bring them to the medical facilities at all. Ebola spread as untrained caregivers were exposed to infectious materials. Community education on how Ebola is transmitted, barrier nursing, and proper infection control and burial are critical to optimal outbreak management. Family engagement (albeit at a safe distance) provides reassurance that relatives are being well treated. These are examples of the importance of social factors and community risk communication in responding to medical emergencies.

The current DRC outbreak poses significant challenges due to the absence of security and diminishing supplies of vaccines and treatments. Additional medical supplies can help reduce future infections, improving security can facilitate identifying and treating infected patients and prevent additional cases, effective community engagement can allay fear and encourage behavior to reduce the risk of disease transmission.

It's time to take climate change seriously  

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. 

Typhus, an old disease, returns to U.S. cities

Increasing numbers of murine typhus in humans were detected in communities in Texas and California in recent months. Typhus is a bacterial disease fleas carry and is transmitted when fleas bite humans. Domestic animals, such as dogs and cats, as well as mice and rats may act as disease vehicles for typhus by carrying infected fleas to places where people live. Although health authorities in Texas speculated the outbreak may be attributable to flea infestation among household pets[i], health authorities in California believe homelessness is playing a role in transmission[ii]. People who are homeless or poorly housed face an increased risk of flea exposure because they spend a large percentage of their time outdoors in unsanitary conditions.

Medical recommendations to limit the spread of typhus include reducing flea populations and treating pets for flea infestation. Notably, the eradication of typhus in the United States during the mid-twentieth century occurred when the insecticide DDT was used against fleas. In Los Angeles county (California), 67 typhus deaths were recorded in 2017, 59 cases have been recorded during the first nine months of 2018.The Texas state health department reports 519 typhus cases during 2017, more than three times the number that occurred during 2010.

[i] See Houston Chronicle July 24, 2018, https://www.houstonchronicle.com/news/houston-texas/houston/article/Typhus-once-thought-eradicated-continues-to-13102164.php, 

[ii] See WebMD.com, October 10, 2018, https://www.webmd.com/a-to-z-guides/news/20181010/california-typhus-

outbreak-continues-to-grow

Providing healthcare is cost effective

Prevention is less costly than treatment. This is true in a variety of health contexts. Preventing both chronic and infectious diseases and diseases from toxic exposures saves the medical costs of treatment after its onset, reduces the effects of disease consequences, and improves health outcomes. For example, preventing the onset of type II diabetes saves the costs of insulin treatment, reduces the risk of developing kidney and vision problems, and supports the maintenance of optimal health. Likewise the prevention of human papilloma virus infection reduces the risk of developing cervical cancer and the mortality associated with the spread of cancer throughout the body. The prevention of environmental contamination reduces ill health caused by exposure to toxic materials. For example, preventing the runoff of fertilizer into fresh water sources reduces blue-green algae blooms and potential poisoning from contaminated seafood. In terms of population health, preventing the onset of disease helps preserve good health for everyone.

For environmental health, prevention of disease and access to healthcare is even more important because hazard exposure may be widespread. For example, the lead exposure in Flint, Michigan affected everyone using municipal water and was universal. The health consequences for Flint residents, especially the developmental damage in children, are expected to extend over the lifespan. The associated medical and social costs will outstrip the temporary infrastructure cost savings from switching the water supply source. 

One of the most contentious debates in the United States is over the appropriate role of government in providing universal access to healthcare. There are those who would argue that providing healthcare for all is too expensive and would disrupt the existing healthcare market. The primary sources of access to non-emergency healthcare in the U.S. today are employee provided health insurance, Medicaid insurance for those with low incomes and ineligible for employer provided health insurance, and individually purchased health insurance plans. There are different consumer paid costs associated with different healthcare sources and they may range from very low for those whose employers provide generous health benefits and the poor to very high for those who have no other option than to purchase individual policies or those who require ongoing medical management of chronic diseases. Regardless of the source of medical care and access, the society at large ultimately pays for ill health in the community. The society pays the costs of ill-health when ill people call at the hospital emergency department to address an acute health crisis, when ill health affects the ability of people to work, when government resources must be used to control infectious disease outbreaks or remediate environmental contamination, and when disease occurrence disrupts usual activities (such as shuttering public facilities when there is a legionella outbreak),

It is a health truism that the earlier health intervention occurs to prevent or mitigate disease, the more likely an improved health outcome will occur. Access to healthcare is an essential component of this paradigm. While healthcare may be expensive, limiting access to healthcare will result in increased costs to the entire society.

Monkeypox cases identified in U.K.

Public Health England officials announced a second case of monkeypox infection has been identified in the United Kingdom. The patient is being treated at Liverpool University Hospital according to a British Broadcasting Corporation report on September 11. The first case of monkeypox infection was diagnosed at a medical facility in Cornwall on September 7. Both patients are believed to have contracted the disease in Nigeria, where cases were reported during late 2017.

Monkeypox is generally a mild disease in humans and its symptoms include the emergence of fluid filled “pocks: on the skin along with fever and malaise. The disease lasts two to four weeks after symptoms appear. Although it is an infrequent occurrence, fatal cases have been observed. Monkeypox is transmitted by exposure to infected animals or, in a small number of cases, exposure to another infected human via contact with the skin pustules, virus contaminated surfaces, or respiratory droplets. Patient management includes supportive care for fever and malaise and patient isolation to reduce the risk of transmission. The recently reported cases in England are only the second known outbreak of the disease outside Africa.

Algae blooms in Florida pose health threaten human and animal health

Florida is beset by fresh water and salt water algae blooms which are killing wildlife, harming human health, and affecting its economy. Both fresh water and salt water algae blooms are caused, in part, by warm water temperatures and fertilizer runoff from agricultural production. In the past, the blooms have diminished with cooler water temperatures, but the 2018 blooms have been more severe than previously observed and it remains to be seen if they will go away during the winter months. 

The environmental impacts of algae blooms are significant. Some freshwater algae blooms can kill fish by depleting dissolved oxygen and asphyxiating them. They also pose a poisoning hazard to humans and other land animals. Tourism, an important component of south Florida’s economy, is affected because algae contaminated waters have forced local officials to curtail access to recreation facilities. Some salt water red algae blooms are fatal to many forms of marine life because they produce brevetoxins and human consumption of brevetoxin contaminated seafood can cause illness. Additionally, since red algae blooms are carried by tides, they can be aerosolized and carried to coastal communities. Although human exposure to brevetoxin is not generally fatal, it can cause respiratory irritation. Economic impacts include damage to coastal tourism and limitations on outdoor activities.

Local governments have requested state authorities to declare a state of emergency. There is no immediate effective mitigation for the proliferation or effects of fresh water or salt water algae blooms so short-term harm reduction can only be achieved by reducing exposure. Over the longer term, it may be possible to reduce those things that contribute to algae blooms such as fertilizer runoff or other sources of excess nitrogen.

Health officials concerned about spread of Ebola outbreak to conflict area in Congo

Concerns about the Ebola outbreak in Democratic Republic of Congo (DRC) have increased with the total number of cases rising to 112 (84 confirmed/28 probable) as of August 27 according to the World Health Organization and the emergence of the disease in a violence plagued area of northeast DRC. While public health experts have praised the deployment of several experimental treatments to address the crisis, there are significant challenges associated with the movement of medicines and personnel in conflict zones. If health officials cannot travel and operate treatment facilities securely, the outbreak is likely to spread.

The key to controlling an Ebola outbreak is rapidly identifying and treating patients, vaccinating susceptible members of the community, and preventing further spread of disease. Conflict in the outbreak area, along with the flight of people escaping violence, the unsanitary conditions that accompany population displacement, and overwhelming demands on a fragile health infrastructure, make an effective response very difficult. Even if military forces are deployed with health workers to respond to the initial emergency, facilities and supply lines must be secured for the duration of the outbreak in the affected area. Additionally, treatment facilities must have hygienic conditions, continuous and reliable electricity, water purification, safe waste disposal, and safe burial procedures until the last patients are discharged. Also, the medical staff must be protected. Press reports have noted abductions and ransom demands have occurred in the conflict area.

One of the outcomes of the 2012-14 Ebola outbreak in West Africa was a concerted effort to develop new therapies for the disease. The experimental treatments deployed to respond to the current outbreak in DRC include the vaccine that was used earlier this year to control outbreak in western DRC, three monoclonal antibody preparations (ZMapp, REGN -3450/-3471/-3479, and MAb114), and two antiviral drugs (favipiravir, Remdesivir). The vaccine requires refrigeration and the monoclonal antibody preparations and one of the two antiviral drugs require intravenous infusion. Effective outbreak control using these experimental treatments also requires skilled medical personnel for patient management. 

These logistic and support requirements will be extremely difficult to implement in an insecure environment. This outbreak is the first instance of responding to Ebola in an active conflict area. Success in controlling the outbreak will depend on the ability of health officials to work effectively in a challenging environment.

A new death toll estimate from hurricanes Irma and Maria released by Puerto Rico government 

Government authorities in Puerto Rico recently released an update to the estimated number of deaths attributable to the two hurricanes that struck the island in September 2017.[i] The initial death toll of 64 represented those casualties who died from immediate effects of the storm, such as drownings, injuries from wind damage, and other storm surge consequences. What was not included were deaths from the effects of electricity outages, loss of potable water, exposure to dangerous living conditions because of housing destruction, and the deaths of persons who did not receive adequate medical care for pre-existing conditions or injuries during the aftermath of the two storms. The new death toll, 1427, is expected to rise again after additional analyses identify deaths caused by consequences of the storm, even if those deaths did not occur immediately.

Further epidemiological research conducted by the George Washington University of Public Health and other research institutions will provide a better perspective on the number of people that died from the consequences of the storm as well as highlight shortcomings in the response to the crisis in Puerto Rico and the U.S. Virgin Islands. The 2017 hurricane season was particularly difficult with major storms striking Houston as well as Puerto Rice and the Virgin Islands. There were additional challenges associated with responding to emergencies in Puerto Rico and the Virgin Islands, which are far removed from the land transportation infrastructure. The Federal government was not sufficiently prepared with supplies and personnel to respond to the devastation in Puerto Rico and the Virgin Islands on the heels of the massive response that followed hurricane Harvey and Irma on the U.S. mainland. The ongoing Puerto Rican fiscal crisis further limited a robust local response. 

A significant number of people from Puerto Rico remain displaced by storm destruction. Industrial production in the important healthcare sector remains below pre-hurricane levels. Puerto Rico enjoyed important advantages in pharmaceutical and medical supply production before 2018 and it remains to be seen if U.S. authorities will implement favorable policies that will facilitate return to previous production levels and allow Puerto Rico to reorganize its fiscal affairs and regain a measure of stability. Such policies will also influence whether skilled workers who left the island will return and enable an economic recovery. In the meantime, a final accounting of all deaths attributable to the 2017 hurricanes will provide additional and tangible evidence of the destruction and disruption that followed these disasters.

[i] http://www.p3.pr.gov/assets/pr-draft-recovery-plan-for-comment-july-9-2018.pdf

The demographic transition, the labor force, and economic growth

The global community is currently experiencing two distinct demographic trends. In the developed world, population growth has declined from levels observed during the mid-twentieth century and populations in the United States, Europe, Japan, and Russia are growing older. In much of the developing world except China, population growth continues but at a lower rate than during the mid-twentieth century with a larger proportion of their populations being less than 30 years old.[i] Many younger people in the developed and developing world are expected to be less healthy than previous generations and there may be a greater demand for health services due to an increased incidence of chronic disease. In China, the “one child” policy imposed by the government during the latter half of the twentieth century has distorted population dynamics. These trends could have profound effects on economics, national security, and societal stability worldwide. 

The combination of improved health and economic modernization has resulted in a change in family formation. The transition from a subsistence agriculture to an industrial economy has changed the role of children from essential workers on the family farm as other employment opportunities have emerged in industrial and service sectors. Advances in family planning have resulted in women having fewer children, in part because better health means most children will survive into adulthood. These are the main reasons why many industrialized countries are experiencing low, if any, population growth and an increasing proportion of older persons. Given these circumstances, the “dependency ratio,” a measure of the number of active workforce members who are supporting persons who are too young or too old to be in labor force, will increase, even as older workers remain in the labor force into their sixties and seventies. 

A population characteristic worldwide is an increased prevalence of chronic disease among persons who are part of the active workforce, potentially resulting in a greater demand for government resources to support the healthcare needs across multiple age cohorts. The spread of a “western” lifestyle, especially dietary changes and a decline in physical activity, has resulted in a spike of obesity and chronic diseases and affected prospects for future healthy life years in both the developed and developing world. There may also be declines in labor force participation due to poor health. These circumstances could result in lower GDP as well as a greater portion of economic activity being diverted to healthcare needs. One labor force characteristic that could emerge is an increased demand for workers in healthcare industries, especially those that care for older and disabled people. Given the limited number of those who are within the age range of the active workforce, generally those between the ages of 16 and 64, it will be necessary to find labor sources to address these expected requirements as well as workers who will work in other labor sectors to keep developed economies healthy.

China and India, large economies on the cusp of becoming fully industrialized, face some unique challenges based on past preferences for male children in both countries and policies of limiting families to one child during the latter part of the twentieth century in China. The result has been a disparity in the number of females and a limit on the number of potential children in succeeding generations due to a shortage of women compared to men of marriageable age. One response to this situation is seeking mates outside the community. However, there remains a significant number of males who have difficulty finding partners and the specific long-term population effects for China and India are unclear. 

One important impact of an aging population on the United States is the effect it will have on the current social security pension system. Unless the current funding mechanism is changed, the social security pension trust fund will not have sufficient revenue to support future obligations. The funding for social security pensions was created to be self-sustaining as long as the pool of current workers is larger than the pool of beneficiaries; beneficiaries are paid from the revenue collected from current workers. The growing number of retirees at the same time that the number of persons in the active labor force is shrinking means either benefits must be reduced or additional revenue must be found. Immigration has provided an infusion of younger workers previously but may not be able to sustain the system as it is currently configured unless immigration is expanded.

There are numerous academic and government studies addressing the future of the economy and GDP growth given the age structure of the U.S. and other developed country populations. One study from the National Bureau of Economic Research assessed that a smaller labor force will cause a decline in GDP.[ii] Another research paper from the Royal Society (U.K.) Philosophical Transactions B indicates immigration could alleviate concerns about the labor force and pension funding by increasing the size of the labor force with immigration and increasing the length of time older workers may be expected to remain in the labor force.[iii] The current political circumstances in many developed countries on the issue of immigration suggests limited political support for any significant population growth from immigration. It is unclear whether political sentiment will change if there is a decline in the rate of GDP increase.

A shift in economic activity that focuses on efficient and multisector economic production rather than subsistence agriculture and a change in population age structure represent a change from past economic history. It is unclear how market forces and government policies will alter national economies and labor markets in the future. It does seem likely that the future of economic activity will be different.

[i] See Central Intelligence Agency, The World Factbook, “Demographic Profile,” available at ttps://www.cia.gov/library/publications/the-world-factbook/fields/2257.html, on July 15, 2018.

[ii] “The Effect of Population Aging on Economic Growth, the Labor Force and Productivity,” Nicole Maestas, Kathleen J. Mullen, and David Powell. National Bureau of Economic Research Working Paper No. 22452 July 2016 JEL No. J11,J14,J23,J26,O47

[iii] Phil. Trans. R. Soc. B (2009) 364, 3009–3021 doi:10.1098/rstb.2009.0185

WHO reports no new cases of Ebola in DRC since June 6

The World Health Organization reported[i] on July 6 there have been no new cases of Ebola virus disease (EVD) in the Democratic Republic of the Congo (DRC) since June 6, 2018. If there are no new case reports as of July 24, the outbreak will be considered over. Fifty-eight cases and 29 deaths have occurred since the outbreak began on April.

Officials in DRC had the benefit of an available effective vaccine that was developed after the 2013-2016 outbreak that affected Liberia, Sierra Leone, and Guinea. The public health response, which included enhanced case finding and surveillance as well as a “ring vaccination” strategy that reduced transmission by vaccinating contacts of persons exposed to the virus, proved effective in halting the spread of EVD, even after it was detected in a large Congolese city. Additionally other infection control measures, such as conducting safe burials, reduced community exposure to the disease. 

There are likely to be future EVD outbreaks in sub-Saharan Africa. The disease is endemic and the reservoir host, probably one of the bat species in the region, is ubiquitous. However, the lessons learned from previous outbreaks and the existence of an effective vaccine suggests it is possible to limit the uncontrolled spread of the disease in the future.

[i] World Health Organization, “Ebola virus disease – Democratic Republic of the Congo, Disease outbreak news 6 July 2018,” available at http://www.who.int/csr/don/06-july-2018-ebola-drc/en/  on July 6, 2018. 

Current Ebola outbreak is a reminder of the importance of medical logistics

The recent outbreak of Ebola virus disease (EVD)  in Democratic Republic of the Congo (DRC) and the international response serves as a reminder of the need to improve medical logistics in developing countries and the impact medical logistics has on health security and national security. The current EVD crisis is different from the 2013-2015 epidemic in West Africa inasmuch as an effective vaccine is available that can reduce disease transmission. The similarity shared by both outbreaks, however, is the difficulty of moving medical personnel, equipment, supplies and medicines. Inadequate medical logistics capacity remains a significant challenge in controlling the disease in remote areas. This challenge highlights the connection between global health security and economic development and the reasons why transportation infrastructure projects should be a priority.

Effective outbreak response requires quick and efficient deployment of health resources to affected areas. Many of today’s most concerning pathogens, Ebola, influenza, Zika, and Nipah among them, occur in the warmer climates of the developing world. While great clinical strides have been made, the logistic infrastructure in many countries still cannot support the movement and unloading of the large cargo vehicles such as aircraft and container ships that support outbreak responses. Long runways are a specific impediment the current response in the DRC and insufficient cargo handling capacity at port facilities hampered the response to the 2013-2015 outbreak in Liberia, Guinea, and Sierra Leone.

Transportation logistic capacity is often placed in the context of economic development and increasing economic growth. While such a perspective is clearly true, it also has a profound impact on health security by facilitating a robust and rapid response to a health crisis and benefits national security by providing the means to support remote communities against a variety of threats. As such, building and maintaining transportation capability should be a priority for international development aid.

New Ebola outbreak in Democratic Republic of Congo

Another Ebola virus disease (EVD) outbreak was reported in the Democratic Republic of the Congo (DRC) in early May 2018. According to a May 13 report from the World Health Organization, there have been 39 suspected/confirmed cases and 19 deaths. It is the ninth EVD outbreak reported in the country since the disease was first identified in 1976 so DRC has long experience in responding to such a crisis. One recent advance in reducing the spread of EVD since the 2013-2014 West African outbreak is the development of a vaccine, which was demonstrated to be effective against disease spread. The immediate challenges associated with the current outbreak are transporting sufficient vaccine quantities to the remote outbreak areas and implementing stringent surveillance along the Congo River and other transportation routes to monitor the movement of potentially infected persons to areas where the disease has not already occurred.

The international response to the current outbreak has the advantages of the lessons learned from the previous West Africa outbreak, among them early implementation of safe burial practices, diligent surveillance, and early intervention by health authorities. Additionally, appropriate public health messages have been developed to inform and engage local community members about best practices for transmission reduction.

Ebola is endemic and circulating in the forest ecology of central Africa. As such, more outbreaks are likely to emerge until the reservoir is definitively identified and the disease can be controlled at its source. In the meantime, interactions between humans and the reservoir species or incidental hosts will result in the continued emergence of the disease.

Responding to an outbreak of a dangerous infectious disease such as Ebola is never easy and there are always logistic, coordination, and other challenges that must be overcome. However, the past Congolese experience with outbreak response and improvements in international health crisis response mechanisms portend more rapid and effective control of this Ebola disease outbreak.

Perceived Russian Power is defined by President Putin’s ability to pursue strategic goals

During the 1970s Ray Kline, a senior national security official in the U.S. government, described the components of national power in an equation that included population and territory, economic/industrial capability, military capability, strategic goals, and the political will to pursue policies that support the strategic goals. By most measures, Russia is a powerful country; it has a technologically advanced military with a large stockpile of nuclear weapons and a large expanse of territory. Under the guidance of President Putin it has demonstrated the political will to pursue its strategic goals. The Russian population is essential to every element of state power, it is an engine of the economy and a source of military strength. Although Russia has maintained significant influence internationally, it may be facing potential crisis of national power based on continuing low birthrates (below population replacement levels) and a low life expectancy compared to other European countries.

The collapse of the Soviet Union exacerbated a long-standing population crisis. Birthrates remained low and average life expectancy plunged during the nineties, in part due to the disintegration of the healthcare system. Additionally, the Russian economy contracted, only recovering to 1990 per capita GDP levels (as measured in constant 2011 dollars based on a purchasing power parity GDP calculation) in 2006.[i] During the period 2006-2016, per capita GDP only increased by about 4000 dollars. Despite these conditions, Russia has maintained a high level of international influence. Russia has used conventional means, such as military support and intervention, as well as unconventional means, such as covert interference in political processes and elections, against former client states and adversaries. It has also suppressed internal political opposition. The continued success of Russian international influence will depend on whether adversaries mount an active effort against covert interference and whether Russia can improve the lives of its citizens. 

Ongoing sanctions against Russia for its activities have negatively affected the economy and exogenous international conditions have reduced its ability to maintain all of its current international activities. Russian reluctance to open its borders to international migration means there will be few options to increase its population and the labor force. If Russia still manages to expand its influence, it may be because its leadership has mastered the art of harnessing political will in the service of well-defined strategic goals and thus altered the terms of Kline’s power equation.

[i] See data reported by the World Bank at https://data.worldbank.org/indicator/NY.GDP.PCAP.PP.KD?locations=RU on May 10, 2018.

National Security and the opioid crisis

The opioid crisis is getting worse and so have the national security implications. The U.S. Department of Health and Human Services reports more than 42,000 people died from opioid overdoses in 2016, an increase of 27 percent compared to the number of opioid overdose deaths during 2015.[i] The National Institutes of Health estimates more than 2 million persons in the United States experienced a substance use disorder related to prescription opioids during 2016[ii] (notably this number does not include those who experienced a substance use disorder from illicit opioid drugs). Data reported in the U.S. Center for Disease Control and Prevention Morbidity and Mortality Weekly Report indicates deaths associated with misuse of opioid drugs increased four-fold during 1999-2015.[iii] Opioid deaths are preventable deaths and the fact that the problem is getting demonstrably worse is clearly an emergency. One notable feature of the data from 2015-2016 is that the rate of opioid deaths increased most among males age 25-44 but it also increased significantly among all persons age 25-34.[iv] This is an age cohort representing the emerging long-term labor force at the beginning of their productive years and also an important demographic cohort for military service. Opioid abuse is disruptive to many aspects of national security, specifically labor force participation and military service. Additionally it disrupts family formation and can cause encounters with the criminal justice system. Unlike the effects of infectious and chronic diseases, opioid abuse disrupts decision-making processes and prevents its victims from making beneficial choices for themselves and dependent family members. Such circumstances lead to adverse downstream effects for persons who are members of the social network of the individual, with potentially profound impacts to the society. These considerations are the basis for the national security implications of the opioid crisis.

A distinguishing characteristic of the current opioid abuse crisis is one pathway to addiction is the legal medical use of the drug for pain management. Some persons became addicted unintentionally through this pathway. The numbers of opioid prescriptions have skyrocketed over the last two decades. This fact is a partial explanation of why this opioid crisis has affected persons who have not historically been at high risk for the use of illicit opioids. For those that became dependent during the course of their treatment, many turned to illicit opioids when access to prescription opioids ended. The chemical composition of street drugs is generally unknown, and if the product is laced with a synthetic opioid such as fentanyl, the risk of an accidental overdose increases. One of the greatest hazards of the current crisis is the contamination of street drugs with synthetic opioids which are many times more potent than prescription opioids, cocaine, or heroin. 

The physiology of opioid abuse involves chemicals in the drug directly binding to nerve cells and inducing feelings of pleasure and well-being[v]. When opioid tolerance occurs, it requires increasing doses of the opioid to achieve a similar level of pleasure from opioid exposure.[vi] Successful treatment of opioid abuse must address the physiological changes caused by exposure to the drug and an increasing tolerance of its effects as well as any psychological association between using opioids and pleasurable feelings.[vii] Drugs such as methadone decrease the desire to ingest opioids by reducing the craving as well as reducing the symptoms associated with withdrawal.[viii] However the craving for the pleasurable feelings can be a powerful inducement for continuing the use of opioids. More research is needed to develop additional treatment protocols for both the physical and psychosocial complexities of opioid abuse disease. Given the increasing number of persons affected by opioid abuse and the national security implications, policies to reduce the harm and adverse consequences are urgently needed. 

[i] Seth P, Scholl L, Rudd RA, Bacon S. Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants — United States, 2015–2016. MMWR Morb Mortal Wkly Rep 2018;67:349–358. DOI: http://dx.doi.org/10.15585/mmwr.mm6712a1.

[ii] National Institute on Drug Abuse (NIDA), “Medications to Treat Opioid Use Disorder – Last Update March 2018.” Available at https://www.drugabuse.gov/publications/research-reports/medications-to-treat-opioid-addiction/overview on April 22, 2018.

[iii] O’Donnell JK, Gladden RM, Seth P. Trends in Deaths Involving Heroin and Synthetic Opioids Excluding Methadone, and Law Enforcement Drug Product Reports, by Census Region — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:897–903. DOI: http://dx.doi.org/10.15585/mmwr.mm6634a2

[iv] Seth P, Scholl L, Rudd RA, Bacon S. Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants — United States, 2015–2016. MMWR Morb Mortal Wkly Rep 2018;67:349–358. DOI: http://dx.doi.org/10.15585/mmwr.mm6712a1.

[v] American Society of Addiction Medicine, “Opioid Addiction 2016 Facts & Figures.” Available at https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf on April 22, 2018.

[vi] Kosten, Thomas R. and George, Tony P., “The Neurobiology of Opioid Dependence: Implications for Treatment,” Sci Pract Perspect. 2002 Jul; 1(1): 13–20. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/ on April 22, 2018.

[vii] Kosten, Thomas R. and George, Tony P., “The Neurobiology of Opioid Dependence: Implications for Treatment,” Sci Pract Perspect. 2002 Jul; 1(1): 13–20. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/ on April 22, 2018.

[viii] Kosten, Thomas R. and George, Tony P., “The Neurobiology of Opioid Dependence: Implications for Treatment,” Sci Pract Perspect. 2002 Jul; 1(1): 13–20. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/ on April 22, 2018.

Why adequate nutrition for everyone is good national security policy

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. 

Governments exist to create conditions that provide for an orderly and sustainable society. If the population does not have the highest possible level of health, the economy will not operate at its highest possible level of production and the government cannot provide the highest possible security for its citizens.

Can three major companies be an agent of change for healthcare in the U.S.?

The recent announcement by Berkshire Hathaway, JP Morgan Chase Bank, and Amazon of an agreement to create an employee healthcare plan sent shudders through the health insurance sector. It is also astonishing that the proposed entity will not be for profit. The essential requirements for healthcare are well understood: primary care to monitor health status, health screening for early disease detection, education to promote wellness, effective management of chronic diseases and conditions to prevent deterioration, maternal health services for pregnant women and infants, acute/emergency care services for accidents and health crises, and end-of-life care for patients who request it. How these companies collaboratively create a system to address the needs of more than one million employees and their dependents could be transformational for the entire U.S. healthcare sector. 

The most significant challenge facing this effort could be providing acute/emergency care. Hospital based care, which forms the core of emergency/acute services, requires large investments in facilities and equipment. Moreover, it needs to be accessible for all community members because emergency care cannot be refused based on ability to pay. While it is possible that a healthcare collaborative would build dedicated hospitals to service their needs, such an approach may be inefficient if there are existing facilities. Alternatively, the three companies could create an insurance mechanism to pay the costs of providing acute/emergency care to its beneficiaries. This approach potentially could provide an investment infusion that benefits the entire community. In the case of one of the collaborators creating a large job center, such as the plans of Amazon with its HQ2, it may be cost effective to create an acute/emergency care facility to serve the needs of the expected influx of new residents. Cooperating with the local jurisdiction to build a new hospital facility could benefit the expected incoming population as well longstanding community members.

Creating a network of healthcare and dental care providers for primary and specialized care may be a simpler task. Commercial health maintenance organizations such as Kaiser-Permanente are a model of primary and specialty care offering a variety of medical services. Medical care services can be scalable, however there may be a minimum population level below which these services are cost inefficient. In such a case the three companies may negotiate with local health care providers to provide services on a fixed fee contract basis. 

Providing prescription drug benefits to employees and dependents of Berkshire-Hathaway, JP Morgan Chase Bank, and Amazon may present the least disruption to the current benefits package. Regardless of who pays the costs of prescription drugs, beneficiaries will probably continue to obtain their prescriptions from pharmacies by mail or in person. Because the combined labor force of the three companies is large, there may be an opportunity to negotiate directly with drug companies for price reductions or other concessions. 

A collaboration by three large corporations has the possibility of improving healthcare benefits for their employees and dependents. The use of technologies such as telemedicine and advanced artificial intelligence diagnostics to lower costs and improve efficiency may be a model for healthcare for all Americans.

New research findings provide hope for saving bats from white nose syndrome

Research published in a recent edition of Nature Communications describes a vulnerability in the fungus that has killed thousands of bats since 2006.[i] Although “white nose syndrome,” a fungal infection that causes disrupted hibernation and leads to starvation, has not been prominent in news reporting in the last few years, it continues to decimate U.S. bat populations. The study found ultraviolet radiation effectively kills the fungus by causing genetic damage. 

Bats provide critical ecological services including pollination and insect control. The full extent of the impact from massive bat die-offs remains unclear but may include an increase in the number of cases of mosquito-borne infectious diseases as well as reductions in food crops that are dependent on bat pollinators. Altered weather from global warming with longer periods of mosquito activity and more droughts in agricultural areas could make the adverse effects even more severe. Additional research is expected to provide information on the optimal approaches to treating the cave habitats where bats live.

[i] Nature Communications 9, Article number: 35 (2018) doi:10.1038/s41467-017-02441-z

A novel orthopoxvirus outbreak was reported among primates in Italian sanctuary during 2015. The virus source is unidentified but sequencing indicates it is similar to cowpox and mousepox viruses.

Emerging Infectious Diseases recently published a case report of an outbreak of a novel orthopoxvirus among non-human primates (NHP) in an Italian animal sanctuary during 2015.[i] The severity of disease varied among the exposed NHPs, ranging from asymptomatic to fatal. Genetic sequencing of the virus demonstrated it had some similarity with reference samples of cowpox and ectromelia (mousepox). The source of the pathogen was not determined, but population surveys among other mammals in the sanctuary showed orthopoxvirus specific antibodies (IgG) from past exposure in 14 percent of rats and 27 percent of mice and voles. Research findings from evolutionary studies of orthopoxviruses suggest they evolved following specific patterns and hypothesize cowpox virus may be the common ancestor of all orthopoxviruses.[ii] This knowledge may be useful in analyzing the newly discovered variant and may provide insights into its host range.

Orthopoxviruses are double stranded DNA viruses that exhibit a high level of similarity across numerous species-specific variants. Cowpox virus causes infection among a variety of species and vaccinia, which may be descended from cowpox and horsepox viruses, serves as an effective human vaccination strain.[iii] Some NHPs exposed in the Italian outbreak were vaccinated with the human vaccine as a preventive measure and survived. The presence of orthopoxvirus antibodies among other mammals in the sanctuary suggests there continues to be widespread virus circulation in the wild. While the presence of antibodies suggests past infection among wildlife, there may not have been any cases observed simply due to the absence of surveillance in wild animals. 

A concern that has emerged over the last few decades is the development of a human-susceptible pathogenic orthopoxvirus as a biological weapon. The emergence of orthopoxirus cases among NHPs is noteworthy because of the high mortality rate and the fact that NHPs and humans share susceptibility to infection with yatapoxvirus,[iv] monkeypox and cowpox. The virus that was recovered from the infected NHPs in Italy was a novel virus so there is no information on previous cases. Although there is no clinical evidence the novel virus is dangerous to humans, a continuing security concern is the potential development of an orthopoxvirus biological weapon.

[i] Cardeti G, Gruber C, Eleni C, et al. Fatal Outbreak in Tonkean Macaques Caused by Possibly Novel Orthopoxvirus, Italy, January 2015. Emerging Infectious Diseases. 2017;23(12):1941-1949. doi:10.3201/eid2312.162098.

[ii] Essbauer S., Meyer H. (2007) Genus Orthopoxvirus: Cowpox virus. In: Mercer A.A., Schmidt A., Weber O. (eds) Poxviruses. Birkhäuser Advances in Infectious Diseases. Birkhäuser Basel

[iii] Sánchez-Sampedro L, Perdiguero B, Mejías-Pérez E, García-Arriaza J, Di Pilato M, Esteban M. The Evolution of Poxvirus Vaccines. Lefkowitz EJ, Upton C, eds. Viruses. 2015;7(4):1726-1803. doi:10.3390/v7041726.

[iv] Haller, Sherry L. et al. “Poxviruses and the Evolution of Host Range and Virulence.” Infection, genetics and evolution : journal of molecular epidemiology and evolutionary genetics in infectious diseases 0 (2014): 15–40. PMC. Web. 5 Jan. 2018.

The death rate from opioid abuse doubles from 2015 to 2016

The U.S. Center for National Health Statistics released the findings from an analysis of opioid related deaths in the United States for 2016.[i] Among the reported conclusions were that synthetic opioids other than methadone accounted for a doubling of the drug overdose death rate in 2016 compared to 2015 and the rate of drug overdose deaths continued to increase. The age adjusted rate of overdose deaths during 2016 was more than three time the rate measured for 1999.

Opioid abuse continues to be a serious public health problem in the United States. According to 2015 data cited by the National Institutes of Health/National Institute of Drug Abuse, more than ninety people die from an overdose of licit and illicit opioid drugs every day.[ii] This fact has significant economic impact on with economic costs exceeding $78 billion per year for healthcare, addiction treatment, lost productivity, and criminal justice proceedings.[iii] Notably, the coal producing regions of the Midwest are among the most severely affected geographic areas.[iv]

[i] Holly Hedegaard, M.D. and others, “Drug Overdose Deaths in the United States, 1999-2016,” National Center for Health Statistics, Data Brief Number 294, December 2017. Available at https://www.cdc.gov/nchs/data/databriefs/db294.pdf  on December 21, 2017.

[ii] National Institutes of Health/National Institute of Drug Abuse, “Opioid Overdose Crisis,” revised June 2017. Available at https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis on December 21, 2017. 

[iii] National Institutes of Health/National Institute of Drug Abuse, “Opioid Overdose Crisis,” revised June 2017. Available at https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis on December 21, 2017.

[iv] Holly Hedegaard, M.D. and others, “Drug Overdose Deaths in the United States, 1999-2016,” National Center for Health Statistics, Data Brief Number 294, December 2017. Available at https://www.cdc.gov/nchs/data/databriefs/db294.pdf on December 21, 2017

Malnutrition and obesity – how they co-exist and threaten health

The World Bank recently published data that was a stark reminder of poor food security, malnutrition, and its impact on human health. In December 2016, approximately 159 million children worldwide experienced malnutrition and stunted growth and 85 percent of them were in 37 developing countries.[i] Because these children do not consume adequate food and micronutrients, growth and brain development is stalled, often permanently. The introduction of processed and nutrient deficient foods has created a second burden of malnutrition, obesity. In some instances, there may be an incentive to purchase processed foods because they are less costly. Obesity, especially when the consumed excess calories do not provide adequate protein, vitamins, or minerals, increases the risk for chronic diseases. Childhood stunting and arrested brain development have a direct impact on school completion and future earnings. Brain imaging studies show stunted children experience damage to the temporal lobes, which is important for cognitive function and the ability to learn. These effects may extend throughout the lifespan. In older persons, malnutrition causes muscle weakness and poor wound healing.

It is counterintuitive that both malnutrition and obesity can occur in the same person. Obesity occurs when someone consumes too many calories and the excess is transformed into body fat. It can coexist with malnutrition because malnutrition occurs when insufficient protein and other nutrients are consumed to sustain biological processes and causes ill health. Malnutrition may or may not be accompanied by hunger. Someone who is both obese and malnourished may not die from wasting but can die because essential life sustaining biological processes, such as immunity and vascular integrity, are disrupted by the absence of nutrients. Other effects from malnutrition include organ dysfunction and fatigue.

Better food security and nutrition education are essential for improving long-term health outcomes and overall quality of life. Providing information about the nutrients in traditional foods and the nutritional deficiencies of recently introduced processed food provides critical information for optimal food purchases and could improve health outcomes and avoid the health consequences associated with obesity.

[i] Shekar, Meera, “An investment framework for nutrition,” December 2, 2016, The World Bank Group

The health crisis in Puerto Rico after Hurricane Maria – an update 

Almost two months after hurricane Maria struck Puerto Rico, the situation there remains precarious. Reports from the U.S. Federal Emergency Management Agency (FEMA) on November 17 state 59 percent of the island’s residents (almost 2 million) remain without electrical power and about 17 percent (about 640,000) do not have access to potable water. The situation in Puerto Rico is made more complicated by the contamination of many water sources by toxic chemicals and disease causing pathogens. An additional emerging health crisis for Puerto Rico is the stress caused by the destruction and disruption from the hurricane and the resulting consequences for the occurrence of chronic and infectious diseases. 

Scientific studies have shown that stress from trauma triggers an array of physical and psychological responses.[i] The human nervous system is activated and produces stress hormones, which causes in increase in blood pressure. Elevated blood pressure over an extended period of time compromises kidney and heart function and causes the associated chronic diseases. Elevated stress hormone levels are also implicated in immune system activation and dysfunction, affecting the ability to fight infections and delaying wound healing. The damage from hurricane Maria has forced many thousands of people to live in conditions that expose them to mosquitoes that carry diseases and to injuries such as falls, lacerations, and broken bones, from living among debris. The psychological effects of stress include depression, anxiety, and post-traumatic stress disorder (PTSD). 

It will take many months or years to restore the housing and employment lost to the storm. The continuing exposure to infectious diseases vectors and toxic substances from the Environmental Protection Agency (EPA) superfund hazardous materials sites on the island, and nutritional deficits from limited road access and the absence of refrigeration for proper food storage, as well as the health consequences from chronic stress, are expected to have a detrimental effect on those continuing to live in severely damaged areas, especially those areas that remain inaccessible by road. 

The long-term disaster response for Puerto Rico will have some unique requirements due to challenges associated with its distance from the U.S. mainland, its island geography, and the extreme level of destruction. However, it is essential to mount a comprehensive response to preserve health and restore the economy for the island’s 3.4 million U.S. citizens.   
[i] Annual Review of Clinical Psychology 2005 ; 1: 607–628. doi:10.1146/annurev.clinpsy.1.102803.144141. NIH    

Monkeypox outbreak in Nigeria  

Health officials in Nigeria report an ongoing outbreak of monkeypox disease in humans with 94 cases and no deaths according to regional media on November 1, 2017.[i] The initial cases of the outbreak were reported on September 26, 2017.[ii] Monkeypox virus is related to the smallpox virus and it is considered a potential biological weapon if it were genetically modified. The virus was first identified in a laboratory primate in 1958 and the first human case was observed in 1970.[iii] Notably, smallpox vaccination also protects against monkeypox infection and is likely one of the reasons it was not identified in humans until the smallpox eradication effort reduced the necessity of smallpox vaccination. Naturally occurring monkeypox cases in humans causes symptoms similar to human smallpox infection but it has a much lower fatality rate.[iv] 

The animal reservoir for monkeypox virus was identified as tree squirrels living in African tropical rainforests according to research published by the World Organization for Animal Health (OIE) in 2000.[v] Other susceptible species include rope squirrels, Gambian rats, striped mice, and dormice; these species may also serve as host species for maintenance of the virus in the wild. Primates are susceptible to monkeypox and experience mild disease but past research suggests they are not the reservoir based on the absence of persistent infection and transmission by no other route than direct contact.[vi] Human transmission occurs by direct contact with infected animals or people but there has been no evidence human-to-human transmission can sustain the disease among humans.[vii] 

It is likely that recent cases of monkeypox infection in Nigeria are the result of interactions between susceptible infected animals and human communities. Such interactions may have been facilitated by human encroachment on wildlife habitats. Previous outbreak investigations have shown that children are most at risk of severe disease and death.[viii] While the available data do not indicate the HIV status of fatal cases, both Nigeria and the Democratic Republic of Congo have estimated population prevalence percentages for persons age 15-49 of 2.9 and 0.7 respectively (Australia has a population percentage prevalence  of 0.1 by comparison) according to data reported by the World Bank.[ix] Additionally, U.S. Government data shows that 150,000 children under the age of 15, most in sub-Saharan Africa, are infected with HIV as a result of maternal transmission.[x] Having poor health due to other medical problems is associated with more severe disease. The emergence of monkeypox virus disease among humans is a concern because there are only limited and unproven treatment options. However, effective disease surveillance and rapid response can prevent large scale outbreaks. 

[i] All Africa news service, “Nigeria: Monkey Pox - 94 Suspected Cases Recorded in Nigeria – UNICEF,” available at http://allafrica.com/stories/201711020026.html on November 26, 2017.   

[ii] World Health Organization, Weekly Bulletin on Outbreaks and other Emergencies – Week 42: 14-20 October 2017,” available at http://apps.who.int/iris/bitstream/10665/259352/1/OEW42-1420102017.pdf on November 6, 2017.    

[iii] United States House of Representatives Natural Resources Subcommittee on Fisheries, Wildlife and Oceans, “CDCs Role in the Importation and Movement of Animals, Statement of: Nina Marano, D.V.M., M.P.H. Branch Chief Geographic Medicine and Health Promotion Branch Division of Global Migration and Quarantine Centers for Disease Control and Prevention, U.S. Department of Health and Human Services,” June 26, 2008, available at https://www.cdc.gov/washington/testimony/2008/t20080626.htm on November 6, 2017 and Pattyn, S.R., “Monkeypoxvirus infections,” Revue scientifique et technique (International Office of Epizootics), 19 (1), 92-97, available at https://www.oie.int/doc/ged/D9290.PDF on November 2017.   

[iv] World Health Organization Media Centre, “Monkeypox Fact Sheet, November 2016,” available at http://www.who.int/mediacentre/factsheets/fs161/en/ on November 6, 2017   

[v] Pattyn, S.R., “Monkeypoxvirus infections,” Revue scientifique et technique (International Office of Epizootics), 19 (1), 92-97, available at https://www.oie.int/doc/ged/D9290.PDF on November 2017.   

[vi] Pattyn, S.R., “Monkeypoxvirus infections,” Revue scientifique et technique (International Office of Epizootics), 19 (1), 92-97, available at https://www.oie.int/doc/ged/D9290.PDF  on November 2017.   

[vii] World Health Organization Media Centre, “Monkeypox Fact Sheet, November 2016,” available at http://www.who.int/mediacentre/factsheets/fs161/en/ on November 6, 2017.   

[viii] World Health Organization Media Centre, “Monkeypox Fact Sheet, November 2016,” available at http://www.who.int/mediacentre/factsheets/fs161/en/ on November 6, 2017.   

[ix] The World Bank, data, Prevalence of HIV, total (% of population ages 15-49), available at https://data.worldbank.org/indicator/SH.DYN.AIDS.ZS on November 6, 2017.   

[x] HIV.gov (a U.S. initiative to disseminate information on HIV), Global Statistics, available at https://www.hiv.gov/hiv-basics/overview/data-and-trends/global-statistics on November 6, 2017.    

Puerto Rico – Hurricane Maria: A Health Risk Assessment 

Puerto Rico is in a race to prevent dangerous exposures to its residents. The potential hazards are infectious diseases from pathogens in sewage contaminated rivers and streams and poisoning from the twenty-four designated U.S. Environmental Protection Agency (EPA) superfund site floodwaters; EPA reports toxic chemicals, such as tetrachloroethene (PCE) and trichloroethene (TCE) are present.[i] These chemicals are considered probably carcinogenic and carcinogenic respectively.[ii] The Maria hurricane crisis response remains complicated by the absence of electricity for eighty percent of residents connected to the electrical grid and poor communications and road access in remote communities.[iii] Additionally, people may be suffering from treatable or preventable conditions because they may not know about the toxic or disease risks. 

Recent Federal Emergency Management Agency (FEMA) reports detail the current state of recovery on the island. According to the FEMA update of October 18, almost one million residents have not been restored to Puerto Rico Aqueduct and Sewer Authority potable water and only seven percent of the roads are open.[iv] While the military has provided helicopter transport for food and water into isolated communities and evacuation of ill/injured persons for medical care, many residents still do not receive sufficient life sustaining supplies. While cellular phone service has improved to fifty-eight percent customer access (as of October 7)[v] and facilitated the dissemination of emergency text messages, general warnings about the danger of contaminated water supplies may not address whether any specific water is safe for consumption.  Individual water sources must be tested to determine if they are potable. If there are few water supplies available, people may unintentionally choose to drink water of unknown purity. The movement of goods to repair homes is limited by the road access bottleneck. Damage to housing increases the risk of injury from poor living conditions and exposure to mosquito-borne disease, which is a constant concern in tropical environments. 

The hurricane that devastated Puerto Rico was the most severe storm to strike the island since hurricane San Filipe II in 1928 according to the U.S. National Weather Service.[vi] The fragility of Puerto Rican infrastructure, which is attributable to a lack of regular maintenance and other causes, also contributed significantly to the difficulty of recovery/restoration operations. Exposure to hazardous water can be prevented by comprehensive public messages cautioning residents to avoid consumption of water of unknown purity and increased supplies of bottled water. Hazards from living in unsafe living conditions can be mitigated by improving road access and supply delivery or temporary relocation of endangered residents. All possible efforts should be made help Puerto Rico recover from this calamitous hurricane.
 

[i] U.S. Environmental Protection Agency, “Search for Superfund Sites Where You Live,” available at https://www.epa.gov/superfund/search-superfund-sites-where-you-live on October 22, 2017.   

[ii] U.S. Agency for Toxic Substances and Disease Registry, Toxic Substances Portal, available at https://www.atsdr.cdc.gov/toxfaqs/index.asp on October 22, 2017.   

[iii] U.S. Federal Emergency Management Agency, “Hurricane Maria- Maria Updates,” available at https://www.fema.gov/hurricane-maria?utm_source=hp_promo&utm_m on October 20, 2017   

[iv] U.S. Federal Emergency Management Agency, “Hurricane Maria- Maria Updates,” available at https://www.fema.gov/hurricane-maria?utm_source=hp_promo&utm_m on October 20, 2017   

[v] U.S. Federal Emergency Management Agency, “Overview of Federal Efforts to Prepare for and Respond to Hurricane Maria,” available at https://www.fema.gov/blog/2017-09-29/overview-federal-efforts-prepare-and-respond-hurricane-maria on October 22, 2017.   

[vi] U.S. National Weather Service, “Major Hurricane Maria: Wort hurricane in nearly 9- years for Puerto Rico,” available at http://www.weather.gov/media/sju/events/Maria/HurricaneMaria.pdf on October 22, 2017.    

Hurricane Maria and Puerto Rico – Health and Economic impacts  

Puerto Rico was devastated by hurricane Maria, which struck the island in September 2017. The major infrastructure systems, including electricity, transportation, and water purification/sewage treatment were heavily damaged and full restoration will take many months. Other infrastructure systems dependent on these infrastructures, such as communications and banking, will also be degraded for an extended period. Destruction of housing and disruption of communication, transportation, and electricity will have profound effects on the functioning of the island economy and the health of the population. The public health impact from the storm is expected to include increased incidence of infectious diseases, less effective management of chronic diseases, as well as a general degradation of health status. The loss of electricity and the resulting effects on water purification/sewage treatment and communications clearly demonstrates how major infrastructure systems are connected to each other and how some infrastructure systems are mutually dependent on other systems to function.  

The combination of damage to public and personal property indicates the recovery of Puerto Rico will be very expensive. The destruction caused by the hurricane is unprecedented. According to media reports 85 percent of the population continues to lack access to electrical power from the island’s grid, 40 percent lack access to clean water[i], and 80 percent[ii] of agriculture was destroyed. Communications, which are dependent on the availability of electricity, remain crippled and that continues to make comprehensive damage assessment and many banking services unavailable in remote areas. The challenges for the public health response are numerous. The damage to communications and transportation degrades the ability of public health authorities to monitor and mitigate the expected increase in infectious disease and to manage patients with treatment-dependent chronic diseases. The damage to a large percentage of residential dwellings means that many people are living outside, exposed to heat and mosquitoes. Mosquitoes are expected to flourish in the flood waters, raising the transmission risk of diseases such as dengue, chikungunya, and Zika, and placing additional stress on the limited health resources of battered communities. Typhoid disease may surge due to unavailability of sewage treatment and dependence on rivers and streams for drinking water. Road access to remote communities remains affected by debris-strewn roads and flooding. Transport of essential medications to treat prevalent diseases such as diabetes and heart disease remains limited and that, along with difficulties in distributing food supplies, is expected to have an adverse effect on older and sicker community members. The lack of access to electrical power could also affect food processing and storage, potentially leading to increased risks of food-borne disease. 

The crippling of communications outside the major cities is expected to limit the ability of public health authorities to quickly respond to individual health concerns. The advent of electronic medical records means that healthcare providers may not have access to the complete medical records of patients presenting for services outside of their customary treatment settings. Data collected by the Puerto Rican government indicates the three leading causes of death on the island are heart disease, cancer, and diabetes. All of these diseases are chronic and require continuing care. If records for past medical care are not available, the treatment may not be optimal because past test results can not inform treatment decisions. More generally, many more people may become dependent on access to public medical care. 

Restoration of infrastructure, housing, and the economy is likely to take a long time and many competing recovery priorities exist for the limited available resources. Electricity is an infrastructure that is essential to the functioning of other critical infrastructures and the inability to provide hospitals and other healthcare facilities with power increases the difficulty of treating acutely and chronically ill patients. Also, electricity supports infection control by supporting disinfection and it allows the laboratories to run diagnostic tests and clinicians to provide emergency services such as surgery. Lastly, chronic care services such as dialysis and breathing support and food safety resources are not available if there is no electricity. A reliable system of communication that covers the entire island is another important priority. Restoration of communications would facilitate public health surveillance and access to some banking services so health service institutions could pay staff salaries and purchase essential supplies. Individuals could buy goods to repair damaged houses. Although restoration of road transport can facilitate the movement of goods and personnel into areas where they are immediately needed, in the short term a logistics chain that quickly moves goods is another important priority. It would also make it possible to evacuate patients that require high–level care. Such a transportation system may be based on cargo helicopters until roads can be cleared and repaired. Restoration of water treatment facilities would provide one of the essential services that allows displaced persons to return to their homes and begin restoration activities. 

The recovery and associated needs assessments from hurricane Maria are in their earliest stages. Emergency response resources are arriving but the true scope of the disaster remains incompletely assessed. We do know the level of destruction is massive and people continue to suffer significant aftereffects. Formulation of a well-considered plan to reconstruct the lost infrastructure will ease the suffering of the Puerto Rican victims.  

Although the unemployment rate in Puerto Rico is twice the rate of the United States, many people on the island receive health insurance from their employer. The damage to industrial facilities will affect access to care for those who have lost jobs, the ability of the local government to fund public health services, and the ability of the economy to recover to pre-hurricane production activities. The level of devastation in Puerto Rico may also result in massive migration from Puerto Rico to the U.S. mainland as workers are displaced from their homes and employment. Since Puerto Ricans are U.S. citizens, they are free to relocate anywhere within the United States. Early estimates for restoration for electricity throughout the island are at a minimum many months and may require an entire year. In addition to residential destruction which will affect the ability of the workforce to live in the most severely affected areas, some of the important industrial facilities on the island, which include agriculture and pharmaceuticals, will experience significant disruption until the electrical grid is restored. The decline in economic production and the departure of workers could further destabilize Puerto Rico’s precarious economic condition. The government already faces a debt restructuring and an additional reduction in revenue would further compromise its ability to repay its creditors. It remains unknown how much money and time will be required to restore the economy, but Puerto Rico faces the simultaneous economic challenges of depopulation, and loss of economic production, and restoration of critical infrastructure as well as the health challenges of caring for a population living under difficult conditions.

[i]  Oren Dorell, “Nearly 3 weeks after Hurricane Maria, distributing aid across Puerto Rico is a mess,” USA Today, October 9, 2017. Available at https://www.usatoday.com/story/news/world/2017/10/09/puerto-rico-aid-hurricane-maria/741739001/ on October 9, 2017.   

[ii] British Broadcasting Corporation (BBC), “Seven graphics that sum up Puerto Rico disaster,” October 2, 2017. Available at http://www.bbc.com/news/world-us-canada-41447184 on October 3, 2017.    

2017 avian influenza virus infection update – cases detected in humans and animals  

Both human and animal infections with the avian influenza continue to challenge countries around the world. In Taiwan and China, outbreaks of H5N6 an H7N9 respectively have caused significant economic losses among commercial bird flocks[i]. Additionally, China continues to experience human cases of H7N9 avian influenza with both fatalities and serious illness during 2017.[ii]  

Other outbreaks of reportable avian influenza, which include all highly pathogenic subtypes and all H5 and H7 subtypes, have been reported in Asian, African, North American, and European countries during 2017.[iii] The virus was detected in both domestic and wild birds. As in the past, the greatest risk for human avian influenza infection is from exposure to diseased domestic birds in settings such as live poultry markets or while slaughtering and preparing domestic birds for human consumption. The spread of reportable avian influenza viruses remains largely attributable to wild bird migration. The wild birds, which are generally not sickened by infection with the virus, can still shed the virus in their feces. Domestic birds become infected when they interact with wild birds, often by sharing outdoor water sources. 

The occurrence of reportable H5 and H7 subtype avian influenza virus and disease among domestic birds is especially concerning because of the risk of these subtypes mutating from low pathogenic viruses, which cause mild disease in domestic birds, to highly pathogenic viruses, which have high mortality among domestic birds. Notably, severe avian influenza virus disease in humans was generally associated only with infection with highly pathogenic viruses until several years ago. Beginning in 2013, humans infected with low pathogenic H7N9 subtype virus exhibited severe disease with significant mortality in China and this continues through 2017. 

Poultry is one of the most important animal based protein sources in the human diet worldwide. The confluence of husbandry practices that expose domestic birds to wild birds and slaughter/processing practices that expose humans to virus-laden aerosols suggests human and domestic bird cases of avian influenza infections will continue. Surveillance and monitoring will give public health authorities information that will help detect and respond to outbreaks that could lead, by virus mutation, to a human pandemic.  

[i] World Organization for Animal Health, “Update on avian influenza in animals (types H5 and H7) - OIE Situation Report for avian influenza (latest update: 18 September 2017),” available at http://www.oie.int/animal-health-in-the-world/update-on-avian-influenza/2017 on October 2, 2017.   [ii] World Health Organization, “Human infection with avian influenza A(H7N9) virus – China Disease outbreak news  13 September 2017,” available at http://who.int/csr/don/13-september-2017-ah7n9-china/en/ on October 2, 2017.   [iii] World Organization for Animal Health, “Update on avian influenza in animals (types H5 and H7) - OIE Situation Report for avian influenza (latest update: 18 September 2017),” available at http://www.oie.int/animal-health-in-the-world/update-on-avian-influenza/2017 on October 2, 2017.    

The economic costs of health disparities

Recently published data from the U.S. Department of Health and Human Services and the U.S. Census Bureau show the persistence of health disparities for persons of color in the United States for mobility limiting conditions and healthcare coverage. Health disparities can impose costs on economies. 

African-Americans, Hispanics, American Indians/Alaska natives, and non-Hispanic/multiple race persons experienced a higher prevalence of arthritis that limited activity than non-Hispanic whites for the period 2013-2015.[i] The higher percentage differences ranged from 4.2 percent for Hispanics, 7.5 percent for African-Americans, 10.1 percent for Hispanic/multiple race, and 10.5 percent for American Indian/Alaska natives. Disability can have significant effects on employment. The August 2017 unemployment rate for disabled workers was 8.4 percent while the unemployment rate for non-disabled workers was 4.7 percent; a similar difference was observed for August 2016.[ii] All of the reasons underlying differences in unemployment rates for disabled versus non-disabled workers are not clear. Since this data specifically addresses arthritis that limits mobility, it could be that the condition arose during the course of adulthood, after a career path had already been chosen. If mobility is essential to performing the job, it may not be possible to implement a reasonable accommodation that would allow such a worker to continue employment in that specific job. Also there may be factors unrelated to specific job tasks that may affect the ability or a worker to maintain employment. It is clear, however, that the unemployment rate for disabled workers consistently has been measured to be higher than for non-disabled workers.  

In the United States, employer provided health insurance continues to be a major source for medical coverage for employed workers. Notably, disabled workers were also more likely to be employed part-time during 2016 than their non-disabled peers; part-time employment may affect access to employer provided health insurance.[iii] Hispanics and African-Americans age 18-64 were less likely to be covered by any health insurance than their white peers.[iv] In general, persons with chronic diseases but without healthcare insurance experience poorer health because their medical conditions are not appropriately managed. Often such persons only receive care at emergency departments when a medical crisis occurs. Emergency care costs more and is less efficacious. Eligibility for the federal health insurance plan for the poor, Medicaid, is based on income[v] and for one person, the federal income threshold is $16,030. Under the Affordable Care Act, states may choose to cover adults without children.[vi] However, anyone with a job paying more than $7.70 per hour and working full-time (40 hours per week) would not be eligible for Medicaid under the federal guidelines. The federal minimum wage is currently $7.25 per hour so workers at the lowest end of the wage spectrum would not automatically be eligible for Medicaid 

Disparities in employment and medical insurance coverage continue to exist in the United States despite overall improvements in the economy. Eliminating these disparities, especially improving chronic disease management, will provide tangible economic benefits and cost savings.   


[i] Barbour KE, Helmick CG, Boring M, Brady TJ. Vital Signs: Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation — United States, 2013–2015. Morb Mortal Wkly Rep. 2017;66:246–253. DOI: http://dx.doi.org/10.15585/mmwr.mm6609e1   
[ii] U.S. Department of Labor, Bureau of Labor Statistics, Economic News Release - Table A-6. Employment status of the civilian population by sex, age, and disability status, not seasonally adjusted, September 1, 2017, available at https://www.bls.gov/news.release/empsit.t06.htm on September 13, 2017.   
[iii] U.S. Department of Labor, Bureau of Labor Statistics, News Release, “Persons with a Disability: Labor Force Characteristics – 2016,” USDL-17-0857, June 21, 2017. Available at https://www.bls.gov/news.release/pdf/disabl.pdf on September 14, 2017.   
[iv] National Center for Health Statistics, U.S. Census Bureau. Comparison of the Prevalence of Uninsured Persons from the National Health Interview Survey and the Current Population Survey, 2016 and 2017. September 2017. Available from: https://www.cdc.gov/nchs/data/nhis/health_insurance/NCHS_CPS_Comparison092017.pdf.    
[v] U.S. Department of Health and Human Services, Medicaid Eligibility, available at https://www.medicaid.gov/affordable-care-act/eligibility/index.html on September 14, 2017   
[vi] U.S. Department of Health and Human Services, Medicaid Eligibility, available at https://www.medicaid.gov/affordable-care-act/eligibility/index.html on September 14, 2017    

One of the enduring challenges of improving the health of people in developing countries is a shortage of health care professionals. The shortage includes not just medical professionals but also dental health professionals. For example, World Bank survey data shows the United States had about 59 dentists per 100,000 people during 1995-1999 while several sub-Saharan countries had 0.2 dentists per 100,000 (or 2 dentists per million) people for the same timeframe. Poor oral health induces systemic inflammation and inflammation plays a role in chronic disease and cancer, as well as affecting the pathology of infectious disease. Notably, chronic disease is already rising in the many parts of the developing world. Increases in the incidence of diabetes and cardiovascular disease attributable to obesity have already been observed. While any interaction between inflammation caused by poor oral health and obesity is unclear, the role of inflammation in many diseases is well understood.  

The path to improved health outcomes in the developing world is to provide both primary medical and dental care. Primary and preventive medical care has been essential to reducing the burden of infectious among groups that previously had limited access to health care. Given the growing clinical evidence implicating poor oral health in chronic disease, access to preventive dental care could improve health outcomes at a much lower cost than treatment after disease emerges. The economic losses attributable to ill health are well documented; preventing chronic disease by improving access and use of medical and dental care is a wise investment.   

The world faces a crisis unlike any other in modern history. Sea level rise will force the evacuation and relocation of coastal communities around the world. Although the consequences are expected to be especially urgent for many Pacific Island nations, other areas affected by sea level rise are predicted to include the California and Gulf of Mexico coasts, and the coastal areas of south Asia, Western Europe, Latin America, Southeast Asia, and southern Africa according to the U.S. National Oceanic and Atmospheric Administration. [i] Additionally, the United Nations High Commissioner for Refugees (UNHCR) states no existing international law instruments address the plight of people displaced by climate change; so there is no current mechanism for assuring the rights and humane treatment of persons forced to flee across international borders.[ii]  Affected communities, in collaboration with national governments and other stakeholders, would benefit by considering best practices for mitigating immediate hazards and an orderly departure if an area become uninhabitable.


An immediate requirement is to begin contingency planning for the evacuation and resettlement of at-risk communities. A unique characteristic of such a contingency plan is that it may involve the relocation of an entire country, which raises questions of political status of the evacuees in the receiving country (will they be integrated into existing political structures of the receiving country or will they re-create previous governing institutions), how the resettlement location will be determined (the parameters and negotiation process for finding a resettlement location), and the specifics of reconstituting the community (what options will the displaced community have with respect to choosing a similar environment and keeping the old community intact). Some of the same questions must be addressed in the case of an internal relocation of a community. For example, the relocation of Cajun communities of the Mississippi River delta may require a comparable planning process even though the move would occur within the same country. The planning for such a complex contingency must be deliberate and methodical to achieve an acceptable and lasting agreement among all parties.  


There are numerous consequences from sea level rise including flooding, salt water encroachment, and damage to electricity, water, and other infrastructures. While buildings may remain intact, the effects on essential utilities may render the area uninhabitable which will also affect the local economy and any infrastructure or facilities associated with production. For example, salt water encroachment can damage local livestock and crop production. For economies with a high percentage of small-scale farms, sea level rise can represent a significant impediment to community viability if accumulated agricultural resources are lost. Local ecological changes due to sea level rise can also disrupt wildlife and the ecological services they provide for agricultural production, affect the types of infectious disease vectors that flourish, and disturb predator-prey balances. Disintegration of communities and traditions may have societal consequences that disadvantage affected populations as they re-establish their lives far away from their traditional homelands.  


Sea level rise will also affect large cities such as New York City, site of one of the world’s most important financial centers. For cities that play an important role in essential services or infrastructure, plans to address the relocation of such activities would help maintain day-to-day operations and improve reliability in the face of a fast moving crisis. Other public goods, such as transportation, telecommunications (including the internet), and energy production/transmission, will face similar imperatives. These efforts will demand thoughtful and meticulous planning by various stakeholders and inputs from a broad cross section of disciplines.


All of the activities that occurred in abandoned communities must be recreated in the new location. As the new environment is transformed into new human settlements, planning must grapple with the creation of new systems of infrastructure that are resilient and can withstand future climate change effects, mitigate future challenges by careful consideration of how existing lands are repurposed for other uses, and effectively manage limited resources, such as water, that will allow the new communities to thrive.  A plan would need to account for all inputs and waste products needed to support communities and their associated economic activities. Unforeseen innovation is likely to solve some technical problems but it remains necessary to identify issues that will affect the local ecology.   [i] NOAA, “Sea level Trends,” available at https://tidesandcurrents.noaa.gov/sltrends/sltrends.html , on July 6, 2017   [ii] United Nations, “Global Issues – Refugees,” available at http://www.un.org/en/sections/issues-depth/refugees/ on July 10, 2017.    

Initial reporting on the next Federal budget suggests there will be significant reductions in health research funding. The world faces unprecedented threats from infectious diseases for many reasons, encroachments on wild environments, the ease and rapidity of international travel, and the introduction of non-native species into ecological systems. These threats emanate from the necessity to feed growing populations, provide more living space, and to accommodate economic demand for new agricultural products. About seventy-five percent of recently identified infectious diseases among humans originate in animals; other infectious diseases that only affect humans, such as influenza, still cause millions of deaths. It is imperative to continue funding of infectious disease research in humans and animals to understand transmission routes, pathology, and effective prevention strategies.
Pandemics, the spread of infectious diseases worldwide, has been the cause of morbidity and mortality since the beginning of human history. In addition to the loss of life, pandemics cause economic and political consequences. The so-called Spanish flu pandemic of the early twentieth century was responsible for the deaths of millions of people, many of whom were in the most economically productive phase of their lives. The introduction of smallpox to indigenous people in Latin America during the sixteenth century was one of the causes of the decline of the great empires that were built there. The spread of HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) in Africa during the late twentieth century decimated the ranks of young and middle-aged people causing both economic and societal disruption. Although medical science has advanced and can prevent many of the known infectious diseases, novel diseases such as Ebola and SARS (severe acute respiratory syndrome) have caused significant morbidity, mortality, and disruption in recent years. Even if the disease does not have a high mortality rate, the costs of prevention and control may be great.
The modern world is characterized by high levels of connectivity and population concentration in megacities. In many megacities in the developing world, people live in close quarters where person-to-person infection transmission is particularly problematic. International trade and transportation facilitate the movement of people and goods worldwide. Proximity and constant human interaction are two factors that contribute to the spread of infectious disease. Even if border controls could be implemented for international travel, it would disrupt commerce and create large economic incentives to circumvent the border controls. In short, it is impractical and highly unlikely that all movement across borders could be prevented.
Fully funding research on infectious disease provides a way to address these health threats and mitigate the consequences of an emergent and novel infectious disease. When SARS emerged in China during 2003, the research institutions, facilities, and personnel were available to tackle the crisis immediately and rapidly identify the pathogen and its associated epidemiological characteristics. While an effective treatment was not available, the knowledge uncovered by research provided mechanisms to limit the spread of disease. A reduction in research funding would lead to the loss of critical research facilities and technical expertise. History demonstrates novel diseases will continue to emerge due to evolutionary and ecological processes. The United States simply cannot afford losing the resources needed to face the next infectious disease crisis.
Full funding of the infectious disease research agenda is good public health and a wise investment in our security.