Ongoing mass demonstrations protesting the May 25 killing of a detained African American, George Floyd, by Minneapolis police raises the possibility of a spike in COVID-19 cases among participants. Many protesters are African Americans who have been disproportionately harmed by the disease. Many protesters did not wear masks. In some instances, they were unable to maintain a six foot separation from others in the crowd, especially when law enforcement used advancing crowd control tactics and riot control agents against them. Crowding is a major risk factor for the transmission of the SARS CoV-2 virus that causes COVID-19 and the disease is highly transmissible, primarily by exposure to infectious aerosols when people shout or cough. Thus, it is expected that there will be an increase in the number of observed cases during the first half of June 2020.
Additionally, while the specific impact of exposure to riot control agents on susceptibility to COVID-19 infection is unknown, some research does indicate an increased susceptibility to respiratory disease due to tissue damage from riot control agents.[i] [ii] The fact that many protests occurred during daylight hours and outdoors may mitigate some disease transmission. The ultraviolet component of sunlight can destroy the virus and being outside increases the likelihood that infectious droplets dissipate.
General public health measures should be undertaken to reduce the risk of COVID-19 spreading in the aftermath of the demonstrations, particularly in light of significant observed disease transmission from asymptomatic people. All protest attendees would benefit from diagnostic testing to identify any new cases. It is especially important for more diagnostic resources to be made available in communities of color where many of the protestors live. Robust contact tracing for identified cases is also essential. Lastly, antibody testing, to determine how prevalent the disease is among populations in defined geographic areas would assist in public health authorities more effectively responding to any new outbreaks.
Experts agree the SARS CoV-2 coronavirus will likely continue to circulate throughout the summer and into the fall when seasonal influenza infections re-emerge. It is highly probable that both COVID-19 and seasonal influenza will pose significant health challenges through at least the end of 2020. Measures to reduce the spread of COVID-19 before the fall will limit sickness and death from both diseases.
[i] Tear gas: an epidemiological and mechanistic reassessment, Craig Rothenberg Satyanarayana Achanta Erik R. Svendsen Sven‐Eric Jordt . First published: 08 July 2016. https://doi.org/10.1111/nyas.13141
[ii] Abraham JH, Eick-Cost A, Clark LL, et al. A retrospective cohort study of military deployment and postdeployment medical encounters for respiratory conditions. Mil Med. 2014;179(5):540‐546. doi:10.7205/MILMED-D-13-00443
Over 5 million people (estimated cases as of May 21) have suffered COVID-19 infections since the disease emerged in late 2019.[i] During the course of the pandemic, evidence emerged COVID-19 can be spread before the appearance of symptoms and some people have no symptoms at all.[ii] This circumstance complicates efforts to control this highly contagious disease as some countries begin to loosen pandemic restrictions. Diagnostic testing for suspected cases, surveillance to detect asymptomatic cases, continuing research on identifying previously unrecognized symptoms and pathology, and research on the development of immunity in recovered patients will be key components of effectively controlling COVID-19.
It is especially difficult to control an infectious disease if infected persons cannot be identified and continue to spread the infection to others. As of mid-May in the United States, diagnostic testing is focused on persons having symptoms or persons who have been exposed to the pathogen. As a result, persons who are not symptomatic are not widely tested. Some estimates are that as many as 25 percent of COVID-19 infections are asymptomatic.[iii] Without maintaining social distancing and other preventive measures, the coronavirus will likely continue to be spread by people who do not know they are infected.
The accuracy of the diagnostic tests is another challenge to controlling the disease. The first diagnostic tests for COVID-19 were based on the genetic composition of the virus and require significant technology and time to perform, but the results are highly accurate. This diagnostic test is considered to be the “gold standard” of diagnostic tests. When the rapid test was developed, the accuracy was measured by comparing rapid test results to the ‘gold standard” test results using the same clinical sample. On May 14, the U.S. Food and Drug Administration, the regulatory authority for approving medical tests, raised questions about the accuracy of the Abbott rapid test.[iv] The immediate concern arising from uncertainty about rapid test accuracy is people with false negative test results interacting with people who are susceptible to infection. In the case of health care workers, this is especially important.
During the course of the pandemic, health professionals have recognized signs and symptoms of COVID-19 that were not associated with the disease during the earliest phases of the pandemic. This is important for two reasons. First, persons who did not display the expected symptoms may not have been tested or counted among COVID cases. Second, the epidemiological analysis that monitored the spread of COVID-19 was incomplete because it did not capture all transmission events. Thus, the effectiveness of control efforts was diminished. More information about all of the clinical symptoms caused by COVID-19 will modify the case definition and improve diagnosis. It can also improve patient outcomes by allowing doctors to mitigate potentially life threatening symptoms, such as blood clots, that emerge later in the course of disease.
The question of whether recovered patients develop long-term immunity to COVID-19 has become prominent as government authorities seek methods of resuming economic activity. Vaccination or recovery from some diseases, such as smallpox and measles, induces long-term immunity against re-infection. As of mid-May 2020, there is no definitive evidence that COVID-19 falls in that category. Long-term immunity typically develops after infection and recovery from viral disease. While the development of short-term immunity has been observed, the passage of time, measured in weeks, is necessary to prove long-term immunity. This is why it cannot be assumed that recovered patients do not need to follow infection control precautions and they should be tested if COVID symptoms recur.
COVID-19 will remain a public health crisis at least as long as there is no effective vaccine or treatment. To date, the only measures that have slowed disease transmission are those that reduce exposure to the virus. As economic activity resumes, only reducing disease transmission will prevent a resurgence of disease and death.
[i]Johns Hopkins University and medicine Resource Center, available at https://coronavirus.jhu.edu/map.html on May 19,2020.
[ii]Furukawa NW, Brooks JT, Sobel J. Evidence supporting transmission of severe acute respiratory syndrome coronavirus 2 while presymptomatic or asymptomatic. Emerg Infect Dis. 2020 Jul [date cited]. https://doi.org/10.3201/eid2607.201595DOI: 10.3201/eid2607.201595, Original Publication Date: May 04, 2020 and Kimball A, Hatfield KM, Arons M, et al. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020. MMWR Morb Mortal Wkly Rep 2020;69:377–381. DOI: http://dx.doi.org/10.15585/mmwr.mm6913e1external icon, both available on May 20,2020.
[iii] See University of Oxford (U.K.), The Centre for Evidence-Based Medicine, available at https://www.cebm.net/covid-19/covid-19-what-proportion-are-asymptomatic/ on May 20, 2020.
[iv]U.S. Department of Health and Human Services, Food and Drug Administration, Press Release - Coronavirus (COVID-19) Update: FDA Informs Public About Possible Accuracy Concerns with Abbott ID NOW Point-of-Care Test, May 14, 2020 available at https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-informs-public-about-possible-accuracy-concerns-abbott-id-now-pointon May 20,2020.
COVID-19 has sparked the most profound economic crisis unrelated to armed conflict since the 1918 influenza pandemic. Fortunately, there is now far more scientific understanding of disease dynamics to inform the best practices for returning to normal activity. Following are some important considerations for a return to the interactions that underpin the economy.
· Implementing comprehensive disease surveillance. This includes adequate clinical testing to provide an accurate knowledge of who and where newly infected persons are and tracing the contacts of confirmed cases. In the United States, this required level of testing has not been reached. Additionally, it is critical to know who has immunity by testing for antibodies. Anecdotal data suggests there is a significant percentage of infections that are not accompanied by symptoms of disease. Antibody tests are essential for anyone returning to a work situation that precludes the possibility of social distancing.
· Collecting and analyzing virus samples over time. This includes genetic analysis of samples both within communities as well as samples from distant places to provide an understanding of how the virus is mutating. The SARS CoV-2 is a pathogen that can mutate quickly and some mutations directly affect whether a recovered person can effectively fight a new exposure to the virus. This is the reason why health officials monitor new influenza virus strains every year. As with seasonal influenza, if the virus mutates in specific ways, it is possible to acquire a new infection even though one has suffered a previous infection.
· Analyzing clinical data to ascertain why certain characteristics predispose some people to more severe disease. Based on the case reporting, we know that African Americans, Hispanics, and those with pre-existing chronic diseases have much higher rates of death and severe illness than others. A comprehensive analysis of patient health status will help protect those who are most vulnerable to serious disease after exposure to COVID-19.
The consequences of the COVID-19 pandemic have caused more economic dislocation than any event other than war since the beginning of industrial age. However, a failure to thoughtfully and adequately plan for a return to economic production will ultimately be more costly in both lives and treasure.
COVID-19 has sparked the most profound economic crisis unrelated to armed conflict since the 1918 influenza pandemic. Fortunately, there is now far more scientific understanding of disease dynamics to inform the best practices for returning to normal activity. Following are some important considerations for a return to the interactions that underpin the economy.
· Implementing comprehensive disease surveillance. This includes adequate clinical testing to provide an accurate knowledge of who and where newly infected persons are and tracing the contacts of confirmed cases. In the United States, this required level of testing has not been reached. Additionally, it is critical to know who has immunity by testing for antibodies. Anecdotal data suggests there is a significant percentage of infections that are not accompanied by symptoms of disease. Antibody tests are essential for anyone returning to a work situation that precludes the possibility of social distancing.
· Collecting and analyzing virus samples over time. This includes genetic analysis of samples both within communities as well as samples from distant places to provide an understanding of how the virus is mutating. The SARS CoV-2 is a pathogen that can mutate quickly and some mutations directly affect whether a recovered person can effectively fight a new exposure to the virus. This is the reason why health officials monitor new influenza virus strains every year. As with seasonal influenza, if the virus mutates in specific ways, it is possible to acquire a new infection even though one has suffered a previous infection.
· Analyzing clinical data to ascertain why certain characteristics predispose some people to more severe disease. Based on the case reporting, we know that African Americans, Hispanics, and those with pre-existing chronic diseases have much higher rates of death and severe illness than others. A comprehensive analysis of patient health status will help protect those who are most vulnerable to serious disease after exposure to COVID-19.
The consequences of the COVID-19 pandemic have caused more economic dislocation than any event other than war since the beginning of industrial age. However, a failure to thoughtfully and adequately plan for a return to economic production will ultimately be more costly in both lives and treasure.
One of the greatest challenges of the COVID-19 pandemic has been the fact it is a new disease and the first information about its pathology and epidemiology was collected as the outbreak was emerging. Although the virus is related to other coronaviruses that cause human disease, it is proving different in how it spreads and its clinical manifestations. The initial COVID-19 data that was collected in China during the winter of 2019-20 indicated transmission was attributable to symptomatic patients. As the pandemic grew and more data was collected, however, additional data suggested some patients did not display symptoms and therefore transmitted the disease unknowingly.
The change in the U.S. Centers for Disease Control and Prevention public health guidance is the result of this new data. Unlike the early stages of the pandemic when the recommendation was to mask patients only if they exhibited symptoms, the current guidance is for everyone who can tolerate a mask to wear one when in close proximity (less than six feet separation) to others. The new guidance was issued to reduce the transmission from asymptomatic patients, who may represent as much as 25 percent of those who are infected with SARS CoV-2.
As the pandemic continues to grow, there may be other changes in health recommendations for the public. The assessment and analysis of new data improves the public health response and reduces risk of infection for everyone.
Since the beginning of the twenty-first century there have been three outbreaks of a novel coronavirus disease in humans that significantly affected human health. Severe acute respiratory syndrome (SARS) emerged in China in 2002, Middle East respiratory syndrome (MERS) emerged in Saudi Arabia in 2012, and COVID-19 emerged in China in December 2019. In each outbreak, the coronavirus pathogen originated in a bat species and the disease “jumped” to humans via a second, intermediate animal host. The disease was initially transmitted by an interaction between a human and an infected animal and subsequently spread by human-to-human contact. Curtailing bat interactions with humans and other animals that are around humans would reduce the probability of harmful infectious disease outbreaks.
Some human-wildlife interactions are attributable to the loss habitat to economic development or demand for wildlife species as pets or sources of consumer products. The current coronavirus outbreak was traced to a live animal market where numerous species were bought and sold. To reduce human outbreaks from zoonotic diseases, humans must re-think how we interact with wildlife and encroach on their habitats.
One change humans can make is to not merchandise wild animals as pets or food sources. Wild animals live in different ecological systems than humans and have evolved to co-exist with a great diversity of bacteria, parasites, viruses, and other microbes that cause disease in humans. When a diverse group of wildlife are confined in close proximity, as in a marketplace, it increases the possibility of the introduction of a novel pathogen to humans. It also increases the possibility that a novel pathogen, especially a virus, could emerge due to evolutionary pressures as pathogens circulate among diverse species. For example, the coronavirus responsible for the 2002 SARS outbreak is believed to have come from a masked palm civet which acquired it from a bat.
A second change humans can make is to re-think how we encroach on wildlife habitats. One approach is to reduce the probability of human wildlife interactions by preserving adequate habitat areas or locating human activities away from critical feeding and nursery areas. Bats, as a species, sustain numerous virus types. Many of the infectious diseases that emerged since 1976, to include Ebola, Nipah, Hendra, SARS and MERS, originated in bats. At the same time, bats perform a variety of important functions that include pollination of many economically important plants as well as pest control of numerous insects. Bats are an important component of the ecological web and declines in bat populations could have significant consequences in both tropical and grassland environments.
The rate of the emergence of novel diseases, especially novel virus diseases, has accelerated in the last 50 years. Many of these diseases originated in various bat species. The maintenance of healthy bat populations, however, is necessary for pollination and pest control. Accommodation and preservation of bat habitats and removal of bats and other wildlife from crowded live animal markets could reduce the interactions between bats and people and minimize the emergence of harmful infectious diseases.
The COVID-19 virus has spread widely, both inside China and to the rest of the world. One possible transmission pathway that should be considered as part of the ongoing epidemiological investigation is the clandestine movement of wildlife and people across international borders.
Illicit international wildlife trade has been documented to occur and China is actively involved in the sale of wildlife in its live animal markets. Other coronavirus outbreaks, such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) were traced to a wildlife source when those diseases “jumped” to infect humans. A second possibility is the undocumented movement of persons across borders through human trafficking, the illicit drug trade, or other criminal activity. Human trafficking is recognized as a serious problem with many victims being trafficked to provide labor. The illicit drug trade and trade in other controlled products continues to occur because it is highly profitable.
COVID-19 infection has become a significant issue of international concern, both due to its impact on public health as well as on international economics. Investigating how the virus is moving from its source in China should include all possibilities because a thorough understanding of transmission dynamics is essential to controlling the disease.
The exposure to a novel coronavirus in Wuhan, China triggered an outbreak of human disease during December 2019. As of February 10, 2020 there were over 40,000 confirmed cases with over 900 deaths.[i]Genetic sequencing of the novel coronavirus shows it is related to both the severe acute respiratory syndrome (SARS) virus and the Middle East respiratory syndrome (MERS) virus,[ii]which caused human outbreaks in China during 2002 and in the Middle East during 2012. All three coronaviruses have a zoonotic origin. Coronaviruses exist in a variety of wildlife species and the current outbreak is believed to have jumped from animals to humans. In light of the current situation and a history of other coronavirus diseases jumping to humans, the Chinese government ordered the temporary closure of live wildlife markets as a disease control measure. Such markets pose an identifiable risk to human health and the permanent closure of live wildlife markets should be considered.
Close proximity interactions between non-domestic animals of varying species in live markets pose significant human health risks. They provide an opportunity for the spread of infectious diseases between the caged animals and humans who visit the markets. Among the post-outbreak findings from the SARS and MERS outbreaks was that the viruses adapted to humans once it spread within communities. Although much remains uncertain about the current coronavirus outbreak, previous experience suggests a similar human adaptation is possible. Additionally, the fact that the outbreak emerged in a densely populated city such as Wuhan and has spread among people who have not had direct contact with the live wildlife markets raises concerns about its epidemic potential.
Placing several Chinese cities under quarantine, as the government has ordered, could reduce the spread of the novel coronavirus disease outside the most severely affected areas. However, the effectiveness of a quarantine as a control measure is questionable as time passes for logistic (supporting the quarantined population with food and other essential goods) and social/political (the willingness of the population to suspend their usual activities) reasons.
Although it may too late to affect the course of the current outbreak, the permanent closure of live wildlife markets should be considered as a public health policy intervention. Eliminating close interactions among wildlife species and the subsequent exposure of the animals to humans could reduce the risk of another novel disease emerging. History suggests there may be other coronavirus outbreaks with similar characteristics and consequences in the future if no preventive action is taken.
[i]Case counts provided by World Health Organization, available at www.who.inton on February 10, 2020.
[ii]Roujian Lu and others, “Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding,” The Lancet, Published online January 29, 2020 https://doi.org/10.1016/S0140-6736(20)30251-8
A recent surge in the number of measles cases in the United States and elsewhere along with the findings of two scientific studies that reported measles infection reduces the immune response to other diseases points to previously unrecognized public health vulnerabilities for those who have not been vaccinated for measles. The findings, which were described in the fall of 2019[i],[ii], show the pathology of measles infection causes a reduction in the body’s ability to mount an effective immune defense against a disease for which the person has pre-existing immunity (either from infection recovery or successful vaccination) and it also reduces the body’s ability to defend against an infectious disease that is new. Measles one of the most highly infectious viral diseases and has a major impact on the health of children. This circumstance calls for a renewed effort to prevent the spread of measles through vaccination and a robust public health contingency plan to respond the emerging outbreaks.
Although measles was largely eliminated in the United States in 2000, declining vaccination rates encouraged by a campaign to falsely associate measles vaccination with a coincidental increase in autism spectrum diagnoses has led to an increase in measles infections, especially among children. Measles is a reportable disease, so surveillance for disease occurrence is a regulatory requirement and robust. What is less clear, however, are which communities are at greater risk for contracting the disease due to vaccine refusal. For example, communities of children may be based on where they attend daycare or school and may be different than the geographic neighborhoods where they live. This is why contact tracing must be especially precise for both geospatial and temporal data. In addition, the reasons for children not receiving the measles vaccination are not always due to lack of access to healthcare or cost but may be the result of decisions by parents or caregivers to withhold the vaccine. This is why it is useful to ascertain the vaccination status of persons in the community with a high degree of certainty as part of investigating an ongoing outbreak. The fact that measles can only be controlled by maintenance of a vaccination rate greater than 90% leaves communities vulnerable. Other infectious diseases, including those associated with children, could also become more problematic as previously acquired immunity from recovery or vaccination is degraded as a consequence of catching measles.
Measles is not a benign disease. Although children who have become infected generally recover without any long-term consequences, the percentage of children who experience life threatening symptoms such as pneumonia or encephalitis, or death is not insignificant. Childhood measles vaccination is essential for the prevention of measles outbreaks in the United States, serious complications associated with measles infection, as well as other infectious diseases.
[i] V. N. Petrova, B. Sawatsky, A. X. Han, B. M. Laksono, L. Walz, E. Parker, K. Pieper, C. A. Anderson, R. D. de Vries, A. Lanzavecchia, P. Kellam, V. von Messling, R. L. de Swart, C. A. Russell, Incomplete genetic reconstitution of B cell pools contributes to prolonged immunosuppression after measles. Sci. Immunol. 4, eaay6125 (2019
[ii]Choy, Mark S. Wilson, H. Benjamin Larman, Ashley N. Nelson, Diane E. Griffin, Rik L. de Swart and Stephen J. Elledge Michael J. Mina, Tomasz Kula, Yumei Leng, Mamie Li, Rory D. de Vries, Mikael Knip, Heli Siljander, Marian Rewers, David F., Measles virus infection diminishes preexisting antibodies that offer protection from other pathogens. DOI: 10.1126/science.aay6485 (6465), 599-606.366Science
Violence and associated risk factors
Many risk factors are relevant in assessing the potential for violent acts. Information on previous violent behavior and substance abuse should be considered.
The United States experienced numerous mass shootings during 2019 and these incidents have called into question the linkage between mental illness and homicidal violent behavior. A U.S. Government report[i]states mental illness, by itself, does not increase the probability someone will commit violence against others. Patients with mental illness are, in fact, are more likely to be victimized by violence than the general population.[ii]When mental illness occurs simultaneously with other risk factors such as substance abuse, however, there may an increase in violent behavior.[iii]Given this assessment, a more comprehensive mental health screening during the background check process for the purchase of firearms could reduce injuries and deaths from gun violence if such screenings address other risk factors for violence. Substance abuse, and characteristics such as poor impulse control, previous violent behavior, bullying, demonstrated disregard for the welfare of others, aggressive driving, and fire setting are relevant in assessing if it is safe to sell a gun to a prospective purchaser.
Epidemiological analysis is a useful tool for quantifying health risks. It is data driven and can provide an unbiased clinical assessment. Epidemiological data provides the basis for making diagnosis and treatment decisions and also identifies how mental illness and other violence risk factors increase the probability of violent behavior. At the same time, however, there are violence associated risk factors and behaviors that may never be observed by mental health professionals because they do not necessarily trigger a formal mental health evaluation or criminal investigation. For example, animal cruelty behaviors have been retrospectively correlated to later incidents of violence. Unless the animal cruelty incident resulted in a formal investigation, there is no mechanism to capture such information for the background check process.
The challenge of improving the background check process is to incorporate more data that is relevant to a risk assessment for future violent behavior. Documented evidence of antisocial behavior associated with violence could exist in a variety of databases including driving records, local social service agency records, school records, or medical records. Such information as well as Information collected by law enforcement agencies from online sources relating to threatened use of violence, such as racial animus, should be made available to the background check system for review before a gun purchase license is granted.
[i] U.S. Department of Health and Human Services, “Mental Health Myths and Facts,” August 29, 2017 available at https://www.mentalhealth.gov/basics/mental-health-myths-facts on September 22, 2019.
[ii] U.S. Department of Health and Human Services, “Mental Health Myths and Facts,” August 29, 2017 available at https://www.mentalhealth.gov/basics/mental-health-myths-facts on September 22, 2019
[iii]U.S. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention, “The Social-Ecological Model: A Framework for Prevention, available at https://www.cdc.gov/violenceprevention/publichealthissue/social-ecologicalmodel.html on September 23, 2019.
Health is a quintessential element of national security. It is critical to a strong military force, which is the traditional notion of national security. It is also essential to other elements of national security such as the economy, the society, and political equilibrium (specifically the narrowing of health disparities). The simple fact is that if the country’s population is not healthy, it has downstream effects on the entire country.
Recent proposals to further reduce nutrition support for the poor can pose a long-term threat to security because it diminishes the ability of about 13 percent of the U.S. population to achieve optimal health and participate in the various activities that make the United States a strong and secure country. Inadequate nutrition can have an immediate effect on the ability of an adult to work, over time it has detrimental effects on physical and cognitive development in children. Inadequate nutrition in adults and children compromises immune function and increases susceptibility to infectious disease and can play a role in the development and progression of chronic disease. Ill-heath is a significant factor in lost labor productivity and decreased economic production and a significant direct cost to the economy.
Production that does not occur due to labor force non-participation ultimately manifests in decreased economic output and lower government revenue, which will have a direct impact on government funding to provide public services such as internal and external security, education, transportation and electricity infrastructure, and healthcare.
The Constitution requires the federal government to conduct a census every ten years. Among the reasons are to realign congressional representation in the U.S. House of Representatives, apportion funds to pay for federal government functions and infrastructure, and to provide baseline population data for disaster and crisis response.[i] The decennial census is designed to count every person living in the United States without regard to citizenship status. These counts are updated regularly with data collected from the American Community Survey, a statistical estimate of population changes from year to year. All of the above mentioned uses of the census data are critical but none have the same immediate impact as having accurate data when the federal government is asked to respond to a natural disaster or a health emergency. Without accurate data on the number and location of people who are affected by an emergency, the crisis cannot be addressed effectively. Any policy that may encourage people not to respond to the census questions is inconsistent with the requirement specified in the U.S. Constitution and the best interest of the people of the United States.
When a natural disaster strikes a community, immediate assistance is required to save lives and protect property. First responders must have accurate information about how many people could be affected and where they live to do their jobs. A census undercount could result in insufficient resource deployment, leaving some people without appropriate assistance. A public health crisis, such as a severe influenza outbreak, could result in some affected people not receiving treatment if public health responders do not know the total number of people who are at risk of becoming sick due to inaccurate or incomplete census information. Such a circumstance would negatively affect efforts to control the outbreak and limit illness and mortality. Even during an average year, more than 30,000 people die from influenza infection, so the potential for harm is significant. Citizenship status is not important to responding to a natural disaster or controlling a disease outbreak; what authorities really need to know is how many people may need help.
A census undercount has numerous negative effects, maldistribution of federal resources for representation, infrastructure, and social programs as well as an inadequate response to natural disasters and public health crises. Anything that impedes a full count of every person living within the United States will harm the entire country. Every possible effort should be made to accurately count each person resident in the United States and universal participation is critical.
[i]See U.S. Bureau of the Census, https://www.census.gov/about/what.html
Revitalizing infrastructure remains an important imperative for the federal government. Legislation to support the rehabilitation and improvement in transportation, power generation, telecommunications and other nationwide systems could facilitate economic growth and improve population welfare. Although health infrastructure does not receive as much attention in discussion of national infrastructure priorities, it is an essential component that will support the national economy and also improve lives. Any policy proposal to fund infrastructure improvements should include health infrastructure, especially in the areas of workforce, data systems, and crisis response; these areas were identified by a federal study as being critical parts of the national health infrastructure.[i]
While the United States spends about one sixth of its GDP on health related expenses, it still does not reap the same level of tangible benefits as other peer developed countries that spend much less on a per capita basis. Additionally, the emergence of climate change and exotic zoonotic diseases challenges to U.S. heath infrastructure in novel ways. A modern U.S. health infrastructure will need to develop capabilities across human and animal health to optimize benefits to the U.S. economy and residents.
Currently, there are workforce shortages in a variety of health fields including physicians[ii]and veterinarians[iii]. As the U.S. population ages, there is increased demands for health services. Also, for reasons that are not yet clear, the health status of younger Americans is worse that it was for previous generations of Americans at the same age and may be an additional cause of increased health service demand. [iv]Climate change has resulted in changes in disease patterns among animal populations. Previously unknown pathogens will likely increase the demand for veterinary clinical services including animal disease surveillance and outbreak management. Further integration of human and animal health, or “one health” infrastructure, will be essential for building additional health capacity.
Modernization and improvements of health systems, particularly in the areas of telecommunications and cybersecurity will support the needs of health infrastructure by improving medical record keeping and information access when patients are treated. Disease patterns will be identified and outbreak response can be occur more quickly. The recent approval for the merger of CVS Pharmacy and Aetna health insurance suggest a shift from large medical practices to retail health settings for routine healthcare. If stand-alone clinics become an increasingly popular source of preventive and well-being health services, more reliable and comprehensive access to individual medical records will facilitate optimal care.
Effective crisis response to health emergencies requires support from other critical infrastructures because the immediate requirement is to deploy resources as quickly as possible for rescue and recovery. Depending on the nature of the health emergency, such as hurricane response for example, rescue workers may need to get to disaster areas quickly to restore basic health services. Affected health infrastructure may require transportation, telecommunications, and electrical power systems as well as possibly erecting temporary clinical facilities to resume operations. A different health crisis may require specialized clinical isolation and treatment facilities be created to contain a widespread infectious disease outbreak. To the extent that a rapid and efficient response will minimize deaths and more severe health consequences, collaborations between various infrastructure stakeholders would ideally include exercise for a variety of health crisis scenarios.
Health systems and infrastructure are an important area of the overall U.S. infrastructure and must be an integral part of planning nationwide updates and modernization.
[i]See Healthy People 2020, Public Health Infrastructure, https://www.healthypeople.gov/2020/topics-objectives/topic/public-health-infrastructure, accessed on June 9, 2019.
[ii]Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Physicians and Surgeons,
on the Internet at https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm (visited June 06, 2019). See U.S. Department of Health and Human Services, Health Resources and Services Administration, https://data.hrsa.gov/topics/health-workforce/shortage-areas, accessed on June 9, 2019.
[iii]See Journal of the American Veterinary Medical Association, https://www.avma.org/News/JAVMANews/Pages/181215e.aspx?PF=1, accessed on June 9, 2019
[iv] See Blue Cross Blue Shield, “The Health of Millennials,” https://www.bcbs.com/the-health-of-america/reports/the-health-of-millennials accessed June 9, 2019.