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"A Tale of Two Crises: The Looming Physician Shortage"
Posted on Monday, Aug 02, 2021

Alexander Le
Texas A&M School of Public Health '21
Texas A&M College of Medicine '25

At the southernmost tip of Texas, Dr. Arturo Rodriguez oversees a region in constant transition. With the city of Brownsville located adjacent to Matamoros across the U.S.-Mexico border, many residents of both municipalities cross daily for school or work.

As Public Health Director, Dr. Rodriguez led the Brownsville Public Health Department’s COVID-19 response. After the first cases began surfacing last year, his team created a “Threat Matrix” community alert system, keeping residents informed regarding disease spread. As resources became available, he partnered with community organizations and municipal services to provide testing and vaccination clinics. In part due to these efforts, Cameron County and other communities along the Rio Grande now boast some of the highest vaccination rates in Texas.

However, as the pandemic continues well into its second year, Dr. Rodriguez has noticed a looming problem: growing shortages of physicians and other health care workers, critical players in the fight against COVID-19. “Everyone,” he explains, “from doctors to nurses working in our hospitals, clinics, and public health systems are experiencing higher workloads.” He worries that many will ultimately choose to retire early or transition to other careers due to various stressors, including burnout, low wages, and trauma from dealing with past surges.

Increasing numbers of physicians leaving the workforce will weaken the existing health care infrastructure that is currently dealing with yet another rise in cases linked to the Delta variant. The situation in Brownsville is reflective of a larger problem across Texas: shortages of physicians, particularly in rural communities and in primary care specialties, compounded by the pandemic.

A GROWING SHORTAGE

Texas currently ranks 41st out of the 50 states in number of active physicians per 100,000 residents, lagging behind the ten most populous states. Nationally, this physician shortage is projected to worsen over the coming decade; by 2033, the Association of American Medical Colleges projects that there will be a shortage of up to 139,000 physicians nationally, including 55,200 primary care physicians.

The most significant deficits are projected to be in primary care specialties used extensively by rural Texans; namely, general internal medicine, family medicine, pediatrics, and psychiatry. For example, in South Texas, only 79.9 percent of the demand for general internal medicine was met in 2018, and this percentage is expected to decrease to 76.4 percent by 2032. Primary care is critical for basic medical care, including routine cancer screenings and blood pressure checks, that allow patients to prevent or address health problems earlier.

Physician shortages have consequences for communities: studies have found that shortage counties (defined as counties with fewer than one primary care doctor for every 3,500 people) have higher mortality rates and shorter average life expectancies than counties with more doctors available per capita. An investment into training and retaining practicing physicians in these counties would pay dividends in improving life expectancy and quality of life for residents.

THE RESIDENCY BOTTLENECK

The current physician shortage crisis can be attributed to several factors, most prominently of which is unstable, insufficient funding for graduate medical education (GME) programs, including residencies. Before being licensed and able to practice independently, medical school graduates must enter a three-to-seven year residency program, during which they receive intensive training in specialties. Training new residents is crucial to replace retiring physicians, meet the health needs of shifting demographics, and increase physicians in rural and historically-excluded communities. However, the cost of this training can quickly add up: for programs to train a primary care resident in Texas, the annual average cost is $150,000 - which covers salary, benefits, and other associated expenses.

In Texas, residency programs are primarily funded through a federal $10 billion Medicare appropriation distributed nationally each year. In 1997, Congress passed the Balanced Budget Act, capping the number and distribution of Medicare-funded residencies among existing training programs at the time. The legislation also prevented existing hospitals from receiving Medicare funding for any new residency positions added after 1996. Since then, despite increased population growth, high student enrollment, and openings of new medical schools (such as those at UH, UTRGV, and UT Austin) with low in-state tuition, these provisions have remained unchanged, essentially freezing a large number of residency programs at 1996 levels.

While in December 2020, Congress ended this freeze through a stimulus bill that will fund 1,000 new Medicare-supported residency positions over five years, Texas is not guaranteed to receive much, if any, of the funding, and the new positions will be distributed across all 50 states. As a result, the number of residencies is likely to remain stagnant for the foreseeable future, barring significant legislative change.

Medical students who train in Texas residency programs have a high probability of staying and practicing medicine in-state. However, without enough available positions to meet demand, students are more likely to match to out-of-state programs following graduation. This bottleneck stunts the growth of the physician workforce statewide, particularly in rural communities that typically struggle to attract new health care workers.

STATE FUNDING DIFFICULTIES

Historically, Texas has partially supplemented these federal funds, but has reduced state funding in past years. For example, in 2011, Texas lawmakers reduced the budget for training family medicine doctors by 72 percent. Beginning in 2014, advocacy efforts from groups like the Texas Medical Association have resulted in the state legislature funding expansion grants and planning grants that help hospitals develop existing and new residency programs, respectively.

These grant programs, with a large focus on rural health care, have been integral in expanding Texas residency positions to their current status. However, the programs are susceptible to legislative cuts, especially as the impact of the COVID-19 pandemic has created a deficit, possibly leading to future cuts on state GME funding. Without sufficient funds, rural communities’ residency programs are especially vulnerable, such as when the 40-year old Wichita Falls Family Medicine Residency Program was shut down in 2018 due to financial constraints.

In 2019, the number of residency programs in Texas grew to 648. To ensure that this number grows, or is at least maintained, it is integral that the state legislature continue supporting GME expansion efforts. Additional funding will help grow and maintain the size and number of established residency positions.

LOOKING TOWARDS THE FUTURE

While Dr. Rodriguez is concerned about the current state of the health care system in South Texas, he has hope for improvement and envisions a future workforce that prioritizes the pillars of health, such as economic development and language literacy.

“Our region is poised to grow,” he says. “We are already a beacon for waterport and spaceport development - our next frontier pursuit should involve the health care sector.” He expresses the need for lawmakers to prioritize economic expansion alongside medical growth and innovation. In this way, they will be better prepared to handle the daily needs of residents and to combat future pandemics.

Ultimately, planting the seeds of the state’s future health care workforce will not only be cost-effective for communities, but a humane investment into extending the lives of each Texan.

Special thanks to Dr. Christine Blackburn and Dr. Arturo Rodriguez for their guidance on this article.

"Pandemic Preparedness: How Local Food Production & Vertical Farming Can Fix a Weakening Supply Chain"
Posted on Monday, Nov 02, 2020

Eddy Badrina

CEO at Eden Green Technology

The Bush School of Government and Public Service '00
Texas A&M University '98

As the COVID-19 pandemic continues in uncertainty, there is one fact that is undeniable: it has amplified the food insecurity crisis that has been looming on a global scale. The pandemic has exposed the weaknesses of a food supply chain that is highly dependent on global imports, and on domestic food sources that are still thousands of miles away from the consumer. The global consumer, for the most part, has enjoyed cheaper price points for basic foodstuffs, and a more varied selection in the marketplace. However, that access has been a temporary illusion: we are now seeing that the current supply chain is too delicate to withstand pandemic-like external forces, and is not nimble enough to shift from food service to grocery retail and local markets.

For instance, in the last six months, our food supply chain has faced problems at every stage:

Food waste is occurring at the farmer level, because the supply chain cannot pivot. Farmers have had to dump, bury and destroy their crops in response to the pandemic and supply chain disruptions.
Food safety risks from farmers to packers and distributors have grown, and will only increase due to the multiple touch points within the supply chain. The FDA paused inspections from early March to mid July, and we are now seeing the implications. Those same actors are sacrificing food and consumer safety for speed to market.
Unpredictable prices spikes or drops and market shifts have occurred due to bottlenecks or oversupply in the supply chain.
Food banks around the world are being overwhelmed, due to a combination of the demand for food, plus the fact that the current supply chain wasn’t built to benefit them. Meanwhile, a recent Food Banking survey reported 44 countries are experiencing 50-100 percent increase in demand for service.
There has been a spike in global hunger and starvation. The world is on track to double the number of people facing acute hunger to 265 million by the end of 2020.

The solution is broad but simple: build up an infrastructure and supply chain centered more around locally grown foods. This local emphasis ensures consumers can reliably and consistently access basic foodstuffs. Ironically, this doesn’t eliminate the chances for national reach, or international import opportunities. In fact, it provides a foundational base for both supply and demand to expand their market opportunities, as regional networks of local growers can use their excess growth and economies of scale to supply secondary, non-local markets. Additionally, a supply chain that is founded upon local and regional sources allows farmers, ranchers, and growers a more stable market, even if it is smaller. Finally, it focuses on the well-being of the consumer, both in terms of nutrition in their diet, as well as accessibility and safety in where they are getting their food from.

Local Food on a Commercial Scale

Prior to COVID-19, the benefits of “locally grown” were seen as more qualitative in nature. Consumers “felt” good and responsible about buying from local farmers, even if it was for more abstract reasons, and maybe even a little romanticized. Farmers’ markets are perfect examples: they are visited on the weekends, as a chance to get out and as more of an experience, not a necessity. Now, post-COVID, “local” has taken on a new meaning, and the locality of the food supply chain will become more crucial as time passes, especially if more pandemics arise.

What does the new definition of “local” and “locally grown” entail? First, the new definition of “local” or “locally grown” means accountable - regulatory authorities and consumers have more confidence about where their food is coming from. It’s verifiable. “Local” also means safer - less time spent in the supply chain, whether it be in cold storage on farms, processing and packing plants, distribution centers. More time spent on shelves and in the hands of consumers. Handled by less hands, Finally, “local” means accessible - shorter supply chain means more consistency, and less risk of disruption.

One solution that is helping redefine “local” and alleviating the food supply risks associated with pandemics is the vertical farm, a type of CEA (controlled environment agriculture) concept. Because they can take up less space (up to 99% less land than traditional farming methods) and less water (98% in some cases), they are the prototypical answer to helping solve this problem. Most importantly, vertical farms, because of their hydroponic nature, can be placed almost anywhere because of their lack of need for soil, and their small physical form factor.

In addition to their compact footprint, because they are season agnostic, vertical farms can produce year-round harvests of fresh food. The most advanced vertical farms can actually redefine regional and geographic varieties as well, as they are built to be tailored environments that can be modified to grow many international varieties of leafy greens, vegetables, fruits, and herbs, but in a local setting.

Global Trade & The Future of Food

The reality is that, while globalization may look different in the days to come, it is here to stay. Global trade and travel may lessen, but it won’t completely go away. However, we ought to view the local food supply, and the local/regional marketplace, as a healthier, more sustainable, and more secure foundation on which the needs of the population can be met. When you overlay the global market, and the diverse produce and food options that come with it, you have a much more robust nutritional platform that can withstand pandemics and other interruptions in the supply chain.

The historical challenges to local food sources have been scalability, and seasonality, and cost sensitivity. However, there is now a moral imperative for lawmakers, local officials and leaders to ensure that this framework is in place, and that it is being actively supported and encouraged. It is a shift from a supply chain that rewards the merchants, to one that is truly focused and prioritizing the end consumer. The priority ought to be fresh, healthy food delivered to the consumer safely and affordably. Vertical farms are a big part of making that priority a reality.

Posted on Monday, Oct 05, 2020

The Effects of COVID-19 on Sex Trafficking in the United States

Sunitha Konatham,
Unbound BCS Administrator,
Texas A&M Master's of Public Health Candidate '21

COVID-19 has claimed hundreds of thousands of lives in the United States, and the pandemic has impacted many facets of our daily lives with the implementation of social distancing guidelines and widespread shifts to virtual education and work.

However, the spread of coronavirus has also affected social aspects that easily go unseen, such as crime, homelessness, job insecurity, and family instability. Of these social consequences, one that is rapidly rising to the forefront is the crime of human trafficking, particularly sex trafficking.

Human Trafficking

Human trafficking, put simply, is when someone is manipulated, forced, or coerced into providing a service in exchange for something of value, whether it is money, shelter, or other fulfillment of needs. In the case of labor trafficking, the service provided is labor or other services, while for sex trafficking, the service provided is sexual in nature.

The Trafficking Victims Protection Act of 2000 (TVPA) provides a detailed definition of human trafficking that is used to incriminate traffickers, recruiters, buyers, and other individuals involved in sex trafficking or labor trafficking, all while protecting the victims from criminal chargers. Establishing survivors of trafficking as victims instead of criminal accomplices allows them to seek the help they need from the law without fear of the law.

Prevalence

Worldwide, there are about 40.3 million human trafficking victims, and the United States was ranked in the top three worst countries in the world for human trafficking alongside Mexico and the Philippines in the “Trafficking in Persons” 2018 Report by the State Department.

According to a 2015 study by the International Labour Organization, human trafficking generates about $150.3 billion per year. UNICEF reported that human trafficking is the 2nd most profitable illegal activity after drug trafficking, and is lined up to become the first most profitable crime because unlike drugs, which are consumable and can only be sold once, traffickers can profit off the sales of their victims over and over.

Buyers = Demand

Trafficking will always exist as long as there is demand, and according to Geoff Rogers, co-founder of the United States Institute Against Human Trafficking, "The United States is the number one consumer of sex worldwide. So we are driving the demand as a society." This is largely due to the rising availability and consumption of pornography, which is oftentimes produced using victims of sex trafficking and can serve as a motivator for viewers to become buyers. This demand has made human trafficking an extremely lucrative criminal industry, so traffickers have adapted to the new social dynamics of the coronavirus pandemic using three methods for sex trafficking: internet, in-person, and re-victimization.

Internet

COVID has put more at-risk individuals at home and spending more time on their phones and computers while lessening their in-person social interactions. The internet has always been a means for traffickers to trap their victims, as social media and messaging apps allow traffickers to hide behind a screen.

Researchers have found that social isolation during the pandemic has also led to an increase in dating app use, which allows users to message each other anonymously. These apps are all about meeting new people, are often designed for hookups, and many of them allow location sharing. When using the app, users may not be aware of where their personal information is going, which makes it a powerful tool for a predator or trafficker.

In-Person

In-person or street trafficking is what people typically associate with human trafficking, since it is the most common method depicted in the media, as in the movie “Taken”. In the last few decades, recruitment and sale of trafficking victims in a physical space has declined in the wake of the internet, but has risen once again due to COVID, though is still not nearly as common as internet trafficking or trafficking by a known person.

Social distancing and widespread closure of businesses and other institutions means there are simply fewer eyes looking out for and reporting cases of trafficking. The vast majority of human trafficking cases are community-reported, as law enforcement does not have the resources to monitor all the physical and virtual avenues of trafficking. Additionally, victims are highly unlikely to self-report due to barriers to identification including fear of retaliation if they make a report or a false belief that they chose to get into this situation.. Community members are vital in preventing and reporting human trafficking, but social distancing has kept most people in their homes where they cannot be witnesses to trafficking.

Revictimization

It is very difficult for victims of human trafficking to actually realize that they are a victim, let alone leave their traffickers, because when traffickers prey on vulnerabilities of their victims to develop or exploit a romantic or other trusting relationship, the victim may experience a neurological bond known as trauma bonding. Trauma bonding, often coupled with forced drug use or violence, keeps victims trapped by their traffickers or returning to them after they have already left. This bond is the primary cause for re-victimization, which has increased in prevalence during the COVID-19 pandemic because of widespread financial insecurity and social isolation.

Unemployment rates are rising due to COVID-19, and survivors are grappling with fears about what will happen when unemployment funds end, concerns about time-limited programs such as rapid rehousing, and loss of access to critical services. Some may even consider going back to “the life” because of financial uncertainty and the desire for familiarity, despite how difficult their past circumstances may have been.

Many survivors of human trafficking are also experiencing increased feelings of depression and PTSD, because social isolation is reminiscent of victims’ time being trapped by their traffickers. Separating an individual from their social networks and support systems is a tactic that traffickers have used time and time again, as they often isolate their victims to increase their dependency on their trafficker and make it more difficult to reach out for help.

What can you do to help?

The best way to join the fight against human trafficking is to be a safe and educated member of the community who will look for and report trafficking. You don’t have to be law enforcement, a victim service agency, or a prosecutor to keep the community safe from human trafficking; you just need to be willing to speak up when the situation arises.

If you or someone you know needs help getting out of a trafficking situation, the National Human Trafficking Hotline can provide victims with local resources, emotional support, and other services that you may need to escape your circumstances safely.

During the COVID-19 pandemic, anti-human trafficking organizations who serve to provide services and resources to victims of human trafficking free of charge are also struggling financially, so you can support your local anti-human trafficking organization by volunteering your time or donating funds.

National Human Trafficking Hotline:

CALL 1-888-373-7888

TEXT HELP to BEFREE (233733)

EMAIL help@humantraffickinghotline.org

VISIT www.humantraffickinghotline.org

CONFIDENTIAL | TOLL-FREE | 24/7

"Threats to the US Bioeconomy: Infodemics and Cybersecurity Attacks"
Posted on Wednesday, Sep 16, 2020

Threats to the US Bioeconomy: Infodemics and Cyberbiosecurity Attacks

Rachel-Paige Casey, PhD Student at George Mason University's Biodefense program, MS, MIA

The COVID-19 pandemic is prompting more discussion about the benefits of research and development from the life sciences to the economy, but also the effects from wide dissemination of inaccurate information and the endangerment of sensitive scientific data in a period of public health crisis. The bioeconomy is a growing subset of the economy that incorporates several scientific fields: life sciences, physical sciences, agricultural sciences, engineering, computer and information sciences, mathematics, medicine, psychology, and social sciences. The Committee on Safeguarding the Bioeconomy at the National Academies of Sciences, Engineering, and Medicine (NASEM) defines the bioeconomy as the “economic activity that is driven by research and innovation in the life sciences and biotechnology, and that is enabled by technological advances in engineering and in computing and information sciences,” which includes all products, processes, and services that relate to research, development, and innovation in the life sciences and biotechnology fields. Two of the key threats to the bioeconomy are the ongoing infodemic paralleling COVID-19 and cyberbiosecurity breaches from foreign actors probing for information about COVID-19 vaccine candidates.

Infodemiology is the science of infodemics, and an infodemic is “an overabundance of information – some accurate and some not – occurring during an epidemic.” An infodemic is further characterized swift and widespread dissemination of misinformation and disinformation through a plethora of media and informational channels. Misinformation and disinformation both comprise the sharing of erroneous information; however, misinformation is not the result of malicious intent as in the spread of disinformation. Misinformation and disinformation are omnipresent these days, especially on social media platforms, providing inaccurate or misrepresented information about various topics such as vaccine safety, genetically modified organisms, and COVID-19. Dietz, Börner, Förster, and Von Braun remark that misinformation about bio-based products, like vaccines, can undermine consumer confidence in technologies and outputs that support the bioeconomy. Prior to the ongoing pandemic, these types of campaigns were lodged against vaccines, particularly childhood inoculations, to weaken the public’s trust in their safety and efficacy. Most unfortunately, any success in spreading these false theories puts child and public health at risk.

Several conspiracy theories about the emergence of SARS-CoV-2, the pathogen that causes COVID-19, have been circulating, many of which point fingers at technology. One of the more outlandish theories claims that the novel virus is transmitted via the electromagnetic spectrum that carries signals across 5G networks. The cherry on top of the 5G theory is a spinoff claim that global elites orchestrated the pandemic as part of a diabolical plan to provide widespread vaccinations secretly containing tracking microchips that can be activated via 5G technology.

A recent study extracted misinformation about COVID-19 shared on online platforms (fact-checking agency websites, Facebook, Twitter, and online newspapers) and assessed their impacts on public health. The researchers identified 2,311 reports of rumors, stigma, and conspiracy theories in 25 languages from 87 countries. Most of the claims covered illness, transmission and mortality (24%); control measures (21%); treatments (19%), and the origin (15%). The prevalence of misinformation – and disinformation – can have substantial deleterious effects on public health when individuals or groups are deceived by spuriousness, especially during a public health emergency. In COVID-19, this was exemplified by an array of unproven treatments or preventive measures against the virus that range from drinking bleach to fraudulent cure kits. As of 9 September, the Federal Drug Administration (FDA) has issued 113 warning letters to firms marketing sham products claiming to prevent, treat, mitigate, diagnose or cure COVID-19.

Murch et al. defines cyberbiosecurity as “understanding the vulnerabilities to unwanted surveillance, intrusions, and malicious and harmful activities which can occur within or at the interfaces of comingled life and medical sciences, cyber, cyber-physical, supply chain and infrastructure systems, and developing and instituting measures to prevent, protect against, mitigate, investigate and attribute such threats as it pertains to security, competitiveness, and resilience.” Though the tools and techniques of cyberbiosecurity are shared with general cybersecurity, the sheer volume of extremely sensitive personal and health data for most, if not all, of the population, along with the very valuable research and development data relating to the life sciences calls for special attention. Filched data can be used by other countries and companies to bolster their own bioeconomies and profits without the upfront research and development costs. As the world races to develop a vaccine against SARS-CoV-2, several countries are expanding their cyber espionage efforts to steal information from US-based entities.

China, Russia, and Iran are suspected of attempting to access data and information related to the research and development of SARS-CoV-2 vaccine underway in the United States. Foreign espionage is suspected to be targeting US universities and medical biotechnology companies (Gilead Sciences, Novavax, and Moderna) conducting SARS-CoV-2 and COVID-19 research. In July, the Department of Justice indicted two hackers working for China’s Ministry of State Security spy service for conducting a computer intrusion campaign targeting intellectual property and confidential business information. Members of Cozy Bear, most likely a component of the Russian intelligence services, were also caught endeavoring to steal vaccine data. On 11 August, Russia announced that it had approved a vaccine, an event that provoked suspicion that its research and development was involuntarily aided by stolen information, likely from the US. Iran-linked hackers are suspected of targeting employees of the biopharmaceutical company Gilead Sciences by setting up fake login pages to steal passwords. These breaches reveal that there are critical gaps in the framework to safeguard sensitive and valuable scientific material.

In COVID-19, the nation that formulates the first safe and efficacious vaccine against the novel coronavirus will, arguably, gain a strategic and key position as in biotechnology and the life sciences. The international influence associated with that frontrunner status could imbue that country with the ability to adjust or create global norms, laws, and protocols related to the protection of life sciences outputs. Additionally, that state will likely greatly expand its share of the global bioeconomy. While the US is generally considered the current leader in biotechnology and scientific research, China, specifically, is catching up at an unprecedented pace and many other countries are prioritizing innovation in the life sciences to reap its benefits.

The COVID-19 pandemic is further revealing threats to the US bioeconomy, particularly in regard to data and information related to public health and the life sciences. A recent joint call for papers about infodemiology to encourage more research on the topic due to the surge of “excessive, false or misleading information may pose new and serious threats to global health.” Supporting the bioeconomy also entails protecting the bioeconomy by defending the research and development findings, breakthroughs, and outputs from cyber-attacks or incidents.

"Public Health in the Time of COVID-19"
Posted on Tuesday, Aug 04, 2020

John Hellerstedt, MD
Commissioner, Texas Department of State Health Services

In 2018, I was invited to attend the Scowcroft Institute’s Fourth Annual Pandemic Policy Summit. I gave a keynote presentation on the 1918 Spanish Flu pandemic and how it impacted Texas 100 years ago. The summit really spurred my awareness and interest in the potential hazards posed by pandemics. I started investigating the topic further when I was asked to write the chapter Resilience is Key for the book Preparing for Pandemics in the Modern World (available for free download: http://www.tamupress.com/pandemics-ebook/).

So last December, when I began to hear the first rumblings of a strange outbreak of a pneumonia-like illness in China, it immediately grabbed my attention. Although the menace seemed far away, it was clearly a threat nonetheless.

I remember sitting in a meeting on January 21, 2020, the day after the Martin Luther King Jr. holiday. That morning the Centers for Disease Control and Prevention had confirmed the first case of the novel coronavirus in the United States. I commented to my coworkers “this will be the headline news everywhere by the end of this week.” Ten days later, on January 31, we officially activated the Texas Department of State Health Services (DSHS) State Medical Operations Center to prepare for the coming crisis.

Setting up the DSHS coronavirus webpage, www.dshs.texas.gov/coronavirus, was a top priority. We also prepared to launch a media campaign to communicate and engage with the public and earn their trust. Keeping the public informed as this disaster unfolded was, and still is, central to our mission.

At DSHS, we knew it was only a matter of time before the wave would come to our state. DSHS activated the Regional Medical Operations Centers on February 17. On March 4, we made an inevitable announcement: the first positive test result for COVID-19 in Texas. Our state’s patient zero had recently returned from travel abroad and was quickly put under isolation.

Texas Governor Greg Abbott held a press conference on March 13 to declare a State of Disaster for all 254 Texas counties to support efforts to “implement preventative strategies that build on our state’s existing public health capabilities.”

On March 17, DSHS confirmed the first fatality of a Texas resident who had tested positive for COVID-19. Two days later, on March 19, I declared a public health disaster for Texas because it had become apparent that COVID-19 was an immediate threat, posing a high risk of death to Texans through community spread.

Texas’s government agencies officially joined forces to respond to the crisis on March 26 when the State Operations Center integrated DSHS into its unified command structure. From there the response to the crisis has become ever more layered and complex. Our response staff generally work seven days a week, rarely taking a day off. Across the agency, we’ve pulled personnel away from their normal jobs addressing critical public issues to deal with this never-ending COVID-19 emergency.

One of the most striking aspects of this crisis is the way it has come over us in waves. Pandemic planning and response have gone through multiple iterations and are still changing constantly. The scientific community keeps making discoveries and advances in what we know about the virus, how to prevent it, and how to treat it. Unfortunately, this can also sometimes lend an appearance of contradictory information or a lack of reliability, which strains public trust. The pandemic has dragged everyone out of their usual routines and they keep being asked to implement new practices. It’s not surprising that we’re encountering resistance instead of flexibility.

Working together as a state, we initially managed to flatten the curve. Our collective actions prevented COVID-19 from overwhelming the Texas healthcare system capacity earlier in the year. However, hard economic realities and strong desires for life to return to normal began to outweigh the abstract threat of the invisible pandemic. Too many people stopped believing that the public health actions they had been taking to prevent virus transmission were necessary, even though those public health actions had worked so well. People stopped taking precautions and increased unnecessary intermingling with others – leading to a surge in cases, and ultimately more fatalities.

Wild theories and rumors have proliferated along with the virus, spreading through our population and causing collateral damage. But this is not the end of our work as public health servants or as Texans. We can still regain our unity by choosing to work together and protecting each other.

I for one, am not giving up hope and I believe that we can rally to fight this virus together. For now, and for the foreseeable future, we must practice infection control in our everyday lives and continue the struggle to maintain our public health best practices until we have a vaccine and effective medications to prevent and cure COVID-19.

"The Help that Doesn't Come"
Posted on Friday, Jul 03, 2020

Dr. Marc Boswell
Director for the Together For Hope Program
Lake Providence, Louisiana

It has often been said that Louisiana consists of two major parts: New Orleans and the rest of the state.
While residents outside of New Orleans take exception to that joke, the adage exemplifies the cultural
and political importance of New Orleans and the tendency of outsiders to primarily associate Louisiana
with what happens in this major urban area.

Along with most of the United States, Louisianans watched the spread of COVID-19 with a sense that it
would not spread here, to wherever here was other than Washington State and New York City. Louisiana
quickly became disabused of that notion as cases popped up in New Orleans and then began to rapidly
multiply there and in the nearby state capital of Baton Rouge.

From my position in the Louisiana Delta, or the rural, agricultural parishes in the lower Mississippi River
Valley, New Orleans feels like a world away. The fastest route to reach the Crescent City takes roughly
4.5 hours and requires travelers to pass in and out of Mississippi along the way. So, as we watched the
explosion of COVID-19 cases occur in New Orleans in early March, the spread of the disease still felt like
a distant possibility for many Delta residents. In fact, it wasn’t until mid to late March that our first case
arrived in Lake Providence, where I live and work, and our known case numbers remained under twenty
until the middle of May.

Louisiana’s governor, Jon Bel Edwards, responded quickly to the rise in numbers in New Orleans. Pastors
and community organizers throughout the state worked hard to raise awareness of the fact that New
Orleans had rapidly become a hotspot in cases per capita in the nation. Much sooner than many
governors in the South, the Edwards administration began requiring shelter-in-place practices.

In the small Delta town of Lake Providence, these requirements mostly resulted in the closure of public
schools, our one library, and in decisions to take extra precautions at our one nursing home and local
hospital. At our little local community college, however, employees were initially told that they would
continue with classes because they had good janitors who could keep things clean. I wish I was joking.

The Delta is a unique place in our country. Most of our parishes (or counties) are predominantly African
American in demographic background. East Carroll Parish, of which Lake Providence is the parish seat, is
roughly 77% Black and 23% white. Poverty rates are inordinately high, with 63% of our children living at
or below the poverty line and 45% or more of adults living at or below the poverty line.
Ironically, there is tremendous wealth accumulation in the Delta, which makes for some of the widest
gaps in generational wealth in the entire country. Black families, most of whom descend from enslaved
and sharecropping ancestors, typically have family wealth of less than $40K, while many white farming
families have accumulated millions of dollars of generational wealth.

Complicating our struggles with poverty is the geographical isolation of most Delta towns. The nearest
Target or Starbucks, for instance, are 1.5 hours away. Businesses choose not to locate in the Delta either
because of the lack of a customer base or because it has been racialized as “Black” and classed as
“poor.” Political leadership, when it advocates on behalf of the Delta, has typically done so mostly in the
interest of wealthy, white farming families.

I mention this background to illustrate the larger structural issues of dealing with COVID-19 in this
particular place. As COVID-19 cases began to subside and be managed better in New Orleans and Baton

Rouge, the governor began to phase the state back toward normalcy in the middle of May. At that time,
many health researchers predicted that a wave of cases (along with greater access to testing) was
coming to rural areas, and such was precisely the case in the rural space of the Delta. Just as the shelter-
in-place restrictions were being lifted across the state, cases began to explode in East Carroll Parish and
also in neighboring Madison Parish to our south.

East Carroll’s cases hovered around 15-20 throughout April and into early May. As restrictions were
eased, we watched as our numbers shot up to 30, then 60, and over Memorial Day Weekend, they
doubled to 120. Since late May, our numbers have reached over 400, landing us on the New York Times’
top ten list of hotspots per capita in America, along with Madison Parish.
In response, there has been no abundance of resources channeled into the area, which is a numbing
reality to which most residents are accustomed. Half of our families do not have reliable access to the
internet, making virtual learning nearly impossible. Multigenerational families of five to seven people
often share two-bedroom homes of less than 1,000 square feet, making social distancing difficult, not to
mention sheltering-in-place. If it has been uncomfortable and aggravating for wealthy and middle-class
folks to stay in place and educate our children and entertain ourselves, imagine the difficulty of doing so
on a median income of $19k per year and doing so in very close quarters.

In the face of such challenges, I’ve witnessed community members respond boldly and courageously.
Religious congregations, almost all of which are conservative evangelical, complied with the governor’s
orders and found creative, safe ways to worship. Teachers tried to find alternative ways to work with
their students and help them finish the semester. Most people adopted the practice of wearing face
masks, even though they were not required by local businesses until early June.

As is often the case in rural America, we watch the interest of the country be primarily oriented toward
major, urban areas, with considerably less attention given to the challenges and realities of rural space.
This dynamic feels multiplied in the Delta given our geographical isolation and our country’s
troublesome legacy of not being particularly concerned about the well-being of African Americans. With
the dismissal and politicization of the disease at the federal level, and with the state of Louisiana’s
primary focus upon urban centers in the southeastern part of the state, residents of the Delta are not
surprised by the fact that help very often just does not come to our communities. We do the best we
can with the little that we have, but that’s small comfort in face of our rapidly growing numbers.

"Small City, Big Steps"

Posted on Tuesday, Mar 31, 2020

By Michelle Jones, MPH, Epidemiogist for Public Health Department of the City of Brownsville

It was mid-January that our small urban health department, located in Brownsville, Texas, took notice of the danger COVID-19 threatened to launch upon us all. Prior to this, members of our team spoke about the devastation China was experiencing, acting as simple observers of a destruction which we prayed would not visit us. Then the virus left China and landed in South Korea. The tone with which our Director, Assistant Director, Epidemiologist, and Emerging Threats Consultant began to discuss the Coronavirus (COVID-19) implications intensified. These same individuals would become our Coronavirus team. As each new country reported their first infection, the realization of a pandemic circumventing the world and reaching the tip of Texas began to take root.

On January 27th, our team sat down for our first CDC conference call titled CDC Telebriefing: Update on 2019 Novel Coronavirus (2019-nCoV). This call compelled our Public Health leadership to move from observation to active engagement in situational awareness and begin the process of gathering any and all information on COVID-19. The following day our designated Coronavirus team sat down to our first, of what would become daily, Texas Department of State Health Services (DSHS) situation briefings. Armed with what limited information was coming out of China, the World Health Organization (WHO), and news stories, we sat in silent contemplation while David Gruber, Dr. John Hellerstedt, and Dr. Jennifer Shuford reported on the latest authoritative information available at the time. This call would be our daily contact with the Texas Department of State Health Services.

The following 3 weeks were mostly routine. We conducted our essential functions with the alteration of a small portion dedicated to monitoring the cases in the United States for community spread and researching articles coming out of China, World Health Organization, various journals, and news sources. The goal was to decipher what were legitimate sources of information, what could be disregarded, and what was plausible but not stringent enough to change our position on the virus. Research and information was being released at speeds and quantities that made deciphering the good from the bad difficult. It was with this flood of information and need for action that the department made the move to begin a public health outreach campaign with information on preventing influenza. Texas was experiencing an influenza outbreak and the move to push influenza prevention steps would allow the department to begin preventative measures for COVID-19 and avoid any unnecessary fear or panic among our community. The department has one community health worker, and she was given handouts on personal hygiene and proper hand washing techniques, in English and Spanish, to distribute at all public health events and to her participants of the Tu Salud Sí Cuenta project. The public health outreach campaign to prevent the spread of COVID-19 had begun in the form of Influenza prevention strategies and evolved into COVID-19 outreach as information and resources became available.

On the 3rd of March, the Public Health Department held its first All Hazards Preparedness Workgroup meeting. The Fire Department, Police Department, Office of Emergency Management, and Communications were briefed on the situation we had been monitoring. The Public Health Department discussed situational awareness of the nation and of Texas. At this moment Texas had not experienced any community spread. These meetings were intended to be informative and an arena to discuss strategy. In subsequent meetings, the city’s call center was brought in and a script was developed for concerned citizens. A Coronavirus webpage was established the same week, with print and educational materials and resources. On March 6th, a meeting was held with our metro station to discuss disinfection of busses and terminals. In addition, information was provided to our airport on hand hygiene and mitigation strategies.

The week of March 9th, the department was engaged in the White House Briefing call, continued the daily All Hazards Preparedness Workgroup calls, and an informational meeting was held by Cameron County. Friday an emergency meeting was called with our Communications, Enterprise Applications, Business Analysis, and Health Department to discuss the enhancement of our message and develop a telework time frame.

The Emergency Operations Center was activated and the Office of Emergency Management took over the Coronavirus response the following week on the 18th. The mayor read in a declaration of local disaster, Continuity of Operations were completed for all departments within the city, and daily conference calls were established beyond those previously established

The week of March 22nd, the city began discussions with Valley Medical Urgent Care and became the first city in the Rio Grande Valley to establish a drive thru testing site that same week. The health department went on to submit a resolution to the city to expand the department to include surveillance and monitoring of COVID-19. This resolution passed with unanimous support from our commissioners and mayor.

References

CDC Telebriefing: Update on 2019 Novel Coronavirus (2019-nCoV) https://www.cdc.gov/media/releases/2020/a0127-coronavirus-update.html
Nicolaides, C., Avraam, D., Cueto-Felgueroso, L., Gonzalez, M.C., & Juanes, R. (2019, December 23). Hand-Hygiene Mitigation Strategies Against Global Disease Spreading through the Air Transportation Network. Retrieved from https://onlinelibrary.wiley.com/loi/full/10.1111/risa.13438

" 'COVID-19 Winter' Starts in June in the South Hemisphere: Will There Be Treatments and Prophylaxis?"

Posted on Sunday, Mar 22, 2020

Authors: Kristen Kent*M.Phil, Nellie Darling MS, Daniel Lucey MD, MPH, FIDSA
Georgetown University School of Medicine, Washington, DC.
*Corresponding author: krk79@Georgetown.edu

Will the COVID-19 pandemic be over by this summer in the Northern Hemisphere? Too many of us in the Northern Hemisphere forget that June-September is winter in the Southern Hemisphere. Given no human immunity to this novel coronavirus, even if transmission slows during the approaching Northern Hemisphere summer, it will likely increase in the simultaneous Southern Hemisphere winter. Fortunately, before June 2020 results from randomized controlled trials in China, and likely Europe, will give urgently needed results as to whether any drugs are effective treatments for ill patients, and whether any are effective prophylaxis to protect persons from getting infected.

COVID-19 has already been documented in 18 countries in the Southern Hemisphere (Table 1). The recognized ongoing spread in Australia, Brazil, Indonesia, and South Africa suggests that there is more widespread transmission in nations in the Southern Hemisphere than documented by laboratory-confirmed testing. Thus, we should not expect to see a resolution in COVID-19 transmission rates in the world simply because of warmer weather in the Northern Hemisphere.

In fact, circulation of the SARS-CoV-2 that causes the disease COVID-19, Is likely to continue year-round. This transmission pattern diverges from that of SARS-CoV-1, the virus that caused the disease SARS in 2002-2003. Thanks to a massive effort coordinated by the World Health Organization (WHO), SARS did not spread in the Southern Hemisphere before it was stopped July, 2003.

Instead, COVID-19 is most likely to follow the pattern of pandemic influenza pdmH1N1 in 2009. Given the lack of human immunity, like now with Covid-19, pdmH1N1 influenza was transmitted through the June-September summer in the Northern Hemisphere, and was transmitted through the simultaneous winter in the Southern Hemisphere. Sustained transmission of this novel influenza virus in the Northern Hemisphere did decrease, but did not stop, in July and August 2009 (1). Likewise, we should expect to see year-round transmission of the novel coronavirus SARS-CoV-2, given the absence of any pre-existing immunity in humans.

Many clinical trials are currently underway in an effort to find treatments and prophylaxis (prevention) options for COVID-19. One such trial is with Remdesivir, a nucleotide analog that failed in clinical trials for the treatment of Ebola but has in vitro activity against coronaviruses. One very recent clinical trial in the USA is investigating Remdesivir in a multi-center, double-blind study sponsored by NIAID/NIH (2). China initiated one or more randomized controlled trials (RCT) of Remdesivir during their pan-epidemic in Wuhan, Hubei province, and across China. Results from the first RCT of Remdesivir in China are anticipated by late April.

One example of a clinical trial for prophylaxis against infection is with an anti-malarial, chloroquine. This double-blind trial will be coordinated by the University of Oxford in the UK (3). The study is recruiting healthcare workers across 50 sites who will be randomized to either chloroquine or placebo group. Treatment will continue for 3 months or until a subject contracts COVID-19. This trial may not be completed for as long as 5 months, but interim analyses may be reported if clear efficacy or futility are seen.

For the coming “COVID-19 Winter” in the Southern Hemisphere, as well as the “COVID-19 Summer” in the Northern Hemisphere, any effective treatment or prophylaxis proven through randomized controlled trials will be a true “game-changer” based on scientific evidence and nothing less.

References:

The 2009 H1N1 Pandemic: Summary Highlights, April 2009-April 2010. CDC. Updated June 16 2010. https://www.cdc.gov/h1n1flu/cdcresponse.htm
Adaptive COVID-19 treatment trial (February 21, 2020). https://clinicaltrials.gov/ct2/show/NCT04280705
Chloroquine prevention of Coronavirus disease (COVID-19) in the healthcare setting (COPCOV) (March 11, 2020). https://clinicaltrials.gov/ct2/show/NCT04303507

Table 1. Southern Hemisphere Nations with Cases and Deaths. (Data extracted and tabulated from WHO reports though 19 March 2020).
covid-chart-(1).png

"Global Approach, Local Partnerships": Private-Sector Pandemic Flu Business Continuity Planning
Posted on Wednesday, Nov 13, 2019

By Malick Diara, with contributions from Susan Ngunjiri, and Candace McAlester. ExxonMobil Corp. and Damola Adesakin, Fircroft

What’s the private sector got to do with pandemics?

A modern-day occurrence of an influenza pandemic at the scale of the 1918 (H1N1) episode would not only impact communities around the world, but also all local, national and global economies [1]. There is a need to galvanize public, private, for-profit and nonprofit proprietorships for a comprehensive preparedness and response strategy.

Working in silos, the usual preparedness and response players may not realize the level of essential resources that the private sector can bring to the table beyond check writing. Pivotal response items from the private sector can include medicines, food and water, as well as services related to health care, logistics, communication, energy and banking.

It is critical to adequately engage all stakeholders at the operational and executive levels while the public and/or international institutions consciously prepare for the next pandemic or other large-scale outbreaks. The objective of such engagement is to ensure the continued availability and supply of all crucial goods and services while consolidating the existing public- and private-sector infrastructures that could be at risk of disruption during a pandemic [2]. This commitment will help establish a more effective preparedness and response approach, with synergic efforts incorporating private-sector capabilities in addressing identified gaps of common interests [3].

Enablers for multisectoral health synergies

The International Health Regulations issued by the World Health Organization provide an overall health policy context and present the needs for in-country implementation support by multiple stakeholders [4]. The Global Health Security Agenda (GHSA) [5] and the Global Health Security Strategy (GHSS) [6] frameworks can constitute the guiding principles for collaborative efforts among key stakeholders in areas related to:

The prevention and reduction of the likelihood of outbreaks.
Early detection of threats.
A rapid and effective response using multisectorial, international coordination and communication.

Conducted by local health authorities and international health institutions, a country’s joint external evaluation (JEE) [7] can serve as the basis for identifying local needs with potential public and private efforts in developing comprehensive solutions. It is possible to incorporate collaborative efforts into the health scenarios of business continuity plans [8]. Managed by the emergency preparedness and response group of most well-established national and international corporations, these plans can have local, regional and global scales. Stakeholders at any level – local, regional or global – must be educated about the JEE process and the GHSA framework for collaborative and effective private-sector business continuity planning.

Lessons learned from an oil and gas setting
Using ExxonMobil’s experience on business continuity planning for pandemic flu, MERS Corona Virus, Ebola and Zika, we recommend these tasks, organized into five main areas, when partnering with the public sector [8-12]:

Emergency preparedness.
- Obtain disease surveillance information to trigger preparedness and response phases simplified into three levels: preparedness, response and hot standby for outbreaks.
- Create communication channels with local health systems for outbreak response, including contact tracing, quarantine requirements and case management.
Site entry controls and screening.
- Determine the effectiveness of measures for different types of sites in consultation with public health experts and relevant authorities.
- Identify devices and providers certified by health authorities to conduct screening measures for at-risk operation sites, including precautions for travelers and visitors to and from disease risk areas.
Education and awareness.
- Adopt key health messages using scientific evidence, case reporting and recommended measures promoted by local and international public health experts for tailored communications.
- Partner with external experts to conduct, as appropriate, communication and education sessions with company medical teams, providers, general employee populations and management teams.
Prevention and case management.
- Identify local health authority prevention approaches and mechanisms for vaccines and drugs that can be provided to employees, in addition to personal and community measures.
- Identify where diagnostic and treatment capabilities exist locally and work with health authorities and partners to enable their effective use by employees, families and surrounding communities.
External interfaces for community investments.
- Engage and support health authority and partner coordination for adequate internal and external outbreak or pandemic preparedness and response measures.
- Engage local health authorities and other oil and gas companies for synergic efforts and consistent workplace measures across the sector, with joint investments in communities.

Applying key lessons learned from past experiences with pandemic flu business continuity planning and other potentially large outbreaks [8-13], we advise:

Engaging external experts for adequate workplace disease prevention and control.
Considering local health system capabilities and support when developing worksite plans.
Using internal and external operational systems to coordinate workplace disease programs.
Engaging at all levels with business executives for effective measures.
Issuing workforce communications for adequate preparedness and response.
Conducting drills, which are the best way to verify preparedness.

While gaps remain regarding adequate preparedness across sectors for the next pandemic flu [14] or other large-scale outbreaks, synergic efforts between the public and private sectors in addition to communities are essential. Both public- and private-sector health actors should further promote such an approach through public health forums in conjunction with local or global health organizations, as well as through other avenues where the private sector discusses its health, safety and environmental programs [15-18].

References

Garrett, Thomas A. “Economic Effects of the 1918 Influenza Pandemic: Implications for a Modern-Day Pandemic.” Federal Reserve Bank of St. Louis, November 2007.
Scowcroft Institute of International Affairs at The Bush School of Government & Public Service at Texas A&M. “Community Resilience, Centralized Leadership & Multi-Sectoral Collaboration in Pandemic Preparedness” third annual white paper, May 2019.
Blue Ribbon Study Panel on Biodefense. “The Cost of Resilience: Impact of Large-Scale Biological Events on Business, Finance, and the Economy.” U.S. Chamber of Commerce Meeting of the Blue Ribbon Study Panel on Biodefense, July 31, 2018.
World Health Organization. “International Health Regulations,” third edition, 2005.
The White House Office of the Press Secretary. “Fact Sheet: The Global Health Security Agenda,” July 28, 2015.
“United States Government Global Health Security Strategy 2019.”
Global Health Security Agenda Assessments & JEE. Accessed Nov. 6, 2019.
Diara, M., S. Ngunjiri, B Aliyu, S. Jones, A. Brown et al., “A Global Effective Ebola Outbreak Preparedness and Response from an Oil and Gas Company Perspective.” Society of Petroleum Engineers International Conference and Exhibition on Health, Safety, Security, Environment and Social Responsibility, Stavanger, Norway, April 11-13, 2016. doi:10.2118/179375-MS
Diara, M., S. Ngunjiri, A. Brown Maruziak, A. Ben Edet, R. Plenderleith et al, “Prevention and Control of Emerging Infectious Disease Outbreaks in Global Oil and Gas Workplaces.” Society of Petroleum Engineers International Conference on Health, Safety and Environment, Long Beach, California, March 17-19, 2014. doi:10.2118/179375-MS
Diara, M., C.E. Johnson, R.O. Dockins, D.L. Buford, A. Ben Edet et al, “Mitigating Infectious Diseases in Company Workplaces Through Business Partnerships.” Society of Petroleum Engineers European Health, Safety and Environment Conference and Exhibition, London, United Kingdom, April 16-18, 2013. doi:10.2118/164997-MS
Scowcroft Institute of International Affairs at The Bush School of Government & Public Service at Texas A&M. 4th Annual Pandemic Policy Summit Pandemic Preparedness Innovation Forum. College Station, Texas, October 16, 2018.
Society of Petroleum Engineers Online Education. “Public Private Partnerships for (PP4) Global Health Threats” panel sesson and webinar, recorded Jan. 24, 2018.
Society of Petroleum Engineers Online Education. “Addressing Infectious Diseases in Oil and Gas Workplaces: Ebola Prepredness and Response Key Learnings” webinar, recorded April 7, 2015.
Schnirring, L., “Experts detail global pandemic readiness gaps, offer steps.” University of Minnesota Center for Infectious Disease Research and Policy. Accessed Nov. 6, 2019.
International Petroleum Industry Environmental Conservation Association (IPIECA) Health website. Accessed Nov. 7, 2019.
International Association of Oil & Gas Producers (IOGP) Health website. Accessed Nov. 7, 2019.
Private Sector Round Table (PSRT). “Global Health Security Agenda.” Accessed Nov. 8, 2019.
Global Business Group on Health (GBGH). Accessed Nov. 7, 2019.

"Global Health Security 2019: Solidifying a Community of Practice"
Posted on Friday, Aug 09, 2019

Rebecca Katz, PhD MPH
Georgetown University

June 2019

In 2016, Dr. Adam Kamradt-Scott of the University of Sydney and I independently started thinking that the field of global health security (GHS) was evolving, and it was time to hold an international scientific conference. In early 2017, we joined forces to plan a conference and started raising travel bursary funds that would eventually support approximately 100 researchers from 31 low income countries.

In June 2019, approximately 900 participants from 65 countries converged in Sydney, Australia to participate in the first International Scientific Conference on Global Health Security. Participants included academic scholars; local and national governments; international organizations, non-governmental organizations; public health institutions; animal health organizations; security professionals; and the private sector.

The purpose of the conference was multifold. We intended to:

Bring together stakeholders working in global health security to measure progress, determine gaps, and identify new opportunities to enhance national, regional and global health security;
Provide a venue for government officials and International Organizations to share policy developments, hear from the research community, and create a space for side meetings that advance the health security agenda;
Through an open call for abstracts, highlight work from partners around the world, bringing cutting edge, evidence-based research to the community; and
Provide an opportunity for students to showcase their research.

By creating this forum, we hoped to establish and solidify a health security ‘community of practice’. This was particularly important as the discipline has been evolving, and often researchers and practitioners were operating with few proximate colleagues. Many researchers were unaware of ongoing work, and few decision makers were accessing research in GHS, even by professionals within their own countries.

In late April 2018, we opened the call for abstracts, in part as a leap of faith. We knew of high profile, well-published colleagues in mostly Western, prominent research institutions. We were also aware of disparate academics interested in this area of study, as we received occasional emails from early career researchers and students, but we were shocked and delighted to receive over 1100 abstract submissions from all corners of the world. In the end, approximately 250 abstracts were selected by the scientific committee to be presented for oral presentations and an additional 200 abstracts selected for poster presentations.

The conference week opened with a two day military health security summit, with a focus on the Indo-Pacific region. One hundred and seventy military and civilian leaders, organized by the Australian and U.S. military, engaged in dialogue on the role of militaries in GHS with a focus on military medical capabilities, and how to advance military-civilian cooperation in GHS, including exploring the need for common legislative frameworks on biosafety and biosecurity. The military summit was followed by a seminar on whether international law has prepared us for the next pandemic. With the WHO just days before deciding not to declare the Ebola outbreak in the Democratic Republic of Congo and Uganda a public health emergency of international concern, this seminar became a timely debate over the future effectiveness of the International Health Regulations.

The first formal day of the conference was reserved for skills based workshops. Conference delegates selected from workshops on infectious disease modeling, drug resistant Tuberculosis, harnessing the power of partnerships, event based surveillance, the Nagoya Protocol, roles for non-governmental actors in messaging and implementation, drug-resistant STIs, environmental risks, biological risks due to advances in technology, and scaling up health emergency preparedness. The next two days of the conference were a mix of plenary sessions, including the kick off plenary of representatives from Centers for Disease Control around the world, and smaller panel sessions. The panel sessions were broken into themes of health emergencies, emerging threats, partnerships, governance and financing, and new technologies and approaches. Each panel was limited to two to three presenters and a moderator, allowing for significant audience participation and dialogue.

This conference was more than just another gathering. This conference led to the development and adoption of The Sydney Statement, designed to capture our collective thinking on how we define global health security, and priorities for action to develop capacity and improve outcomes around the world. It provided a venue for the head of Africa CDC to find himself in a deep debate with a young intern; for early career legal experts to lead a 200 person discussion on the role of the IHR; for GHS implementers from several African Ministries of Health to meet for the first time and create a virtual network with plans for a monthly VTC to share best practices; for policy makers to be challenged and engage in open discourse around how best to advance GHS; for the leaders of GHS initiatives to engage in constructive dialogue; for governments to learn about research that directly links to their project implementation; for side meetings between donors and recipients- some meeting in person for the first time; and for better understanding the opportunities and challenges associated with private sector contributions to GHS.

GHS2019 clearly established and solidified a health security ‘community of practice’ that should be nurtured and sustained. We are stronger together, and collectively we will advance global health security.

THE SYDNEY STATEMENT ON GLOBAL HEALTH SECURITY
June 2019

Global health security is a state of freedom from the scourge of infectious disease, irrespective of origin or source. It is achieved through the policies, programmes, and activities taken to prevent, detect, respond to, and recover from biological threats. There are numerous challenges that pose significant risk to global health security, including a wide array of pathogens that present an existing and ongoing threat to both individual and collective health, antimicrobial resistance (AMR) and the emergence of currently untreatable infections, the potential for deliberate use of a biological weapon, and the synthesis of eradicated or novel pathogens. The complexity of addressing these challenges is amplified by a multitude of contextual factors. These threats know no borders and have global consequences requiring more effective collective action.

Addressing global health security threats should be guided by the following set of principles:

1. Global health security interventions must strive to be inclusive, equitable, and data driven.

2. A minimum level of disease prevention, detection, and response capabilities are critical for all countries, as epidemics anywhere threaten the health of everyone. Achieving global health security is also intricately linked with efforts to achieve universal health coverage, efforts to strengthen other vital aspects of broader health and security systems, and the Sustainable Development Goals.

3. Governments must cooperate programmatically, organizationally and financially to foster compliance with the International Health Regulations and other associated legal and regulatory agreements to ensure effective global governance of public health emergencies, and in so doing, encourage international organisations and NGOs to maintain the integrity of international norms, respect for human rights, and social justice. Transparent discussion, sharing, and measurement of global health security capacities is vital for achieving this goal.

4. Achieving global health security requires individual, group, and systems decision making and activities that strengthens capacity across all levels of societal interaction and disciplines. Making the world a healthier, more equitable, and safer place requires action and engagement from all, including the philanthropic, public and the private sector.

5. Global health security must embrace a One Health approach, not only to prevent and respond to disease, but also to protect ecosystems that underpin human, animal, and environmental health. All relevant sectors must be meaningfully involved and engaged, including health, agriculture, environmental, security, and other vital components.

6. Countries with higher capacity to respond to adverse public health events have a moral and ethical duty to work in partnership with those with lower capacity to strengthen their capabilities in a sustainable manner.

7. International partners and national governments must commit to sustainable, comprehensive funding mechanisms to support global health security.

Long-term strategic thinking for global health security must be supported by a diverse, inclusive community of practice, committed to providing the best evidence possible to inform transparent decision making. Achieving global health security requires commitment to the above principles, and the institutional arrangements that advance them globally, to reduce infectious disease threats, including local empowerment, capacity building, data and benefits sharing, transparency, and accountability. Stronger health systems, Universal Health Coverage, and Health-In-All-Policies, from the local to the global levels are all dependent upon and supportive of global health security.

"Ebola in the DRC: Distrust of Responders or Bad Understanding"

Posted on Friday, Jul 05, 2019

By Robert Kahumula
World Health Organization, Risk Communication and Community Engagement Officer

From 1976 to 2018, the DRC has been affected by 10 epidemics, almost all in rural areas. The current epidemic is more unique because it affects two provinces at the same time, in both urban and rural areas, with a large number of victims, and around 65% of cases resulting in death (MOH, April 28th). The Ministry of Health and its partners have developed several strategies that have proved ineffective (3rd strategic plan of January 2019).

Despite the deployed human resources both nationally and internationally, with high expertise by the DRC Minister of Health and its partners, including the World Health Organization (WHO), in addition to the local recruited people, the epidemic continues, with an average of approximately 70 new positive victims every week. These stats are less than they were before June 2019.

The population in Butembo and surrounding areas has problems perceiving the Ebola Virus Disease, due to the practices of the response agents, as well as the rumors around this disease. Contributing to rumors is the fact that the first people to talk about the EVD were foreigners, which is normal because the region had not experienced the Ebola epidemic before.

Explanations of this new disease in the area exceed the expectations of the residents, especially when the response agents practice what they prohibit the residents from doing, in terms of self-prevention. Several people including those who do not know anything came from all over just to get money from the response. These outsider efforts are causing the resistance and distrust of the teams.

In addition to what is written above, the health sector has a system in place that the population is used to. The government, though, responded by bringing foreigners to assist each of the commissions, while the population only has confidence in their local doctors and nurses who work in the different health centers and hospitals. Because most local health workers are not paid by the government, they are not considered in the response plans. That is why they are sometimes dissatisfied; they oppose the government response by hiding the patients who end up dying either in the health centers or in the community, thereby contaminating family members, caregivers and other patients. Additionally, many times they advise the inhabitants not to be receptive to the actions of the teams of the EVD response. It is also not understood that people will be infected if the health centers are in poor condition. The absence of a sorting system, water, sanitation, toilets, and isolated baths in these centers is a serious problem and causes many nosocomial infections of EVD. The population thinks that the response teams don’t want to end the Ebola epidemic because they earn money through the response.

Moreover, the population does not understand why they have to send a patient to Butembo or Beni, several kilometers from his home, for care, receiving clothes and meals for free, rather than to his doctor or nurse closeby. This is scary for everyone, especially because many people think that only foreigners work at the Ebola Treatment Center (CTE).

The wish is to install transit centers in hospitals where samples can be taken to Ebola centers. It's a way to bringing care closer to people. Some go further by wanting Ebola care to be integrated into the healthcare system, insinuating, for example, that if you build a hospital for only HIV, no one will go because of the shame and stigma attached to the disease.

The community does not seem to have the real leaders able to confront these challenges. Community leaders, religious and customary, who try to raise awareness, are accused of corruption by the response team. Some candidates even claimed during the last election campaign the illegitimacy of the disease. These people have gone unpunished.

New information and communication technologies are also used to reinforce misinformation and resistance: bad-will people post false messages and intimidate about announcing the attacks. These messages are distributed among young holders of smart phones, which prompts more resistance.

Currently, the number of EVD cases is decreasing mainly in Butembo, but remains scattered in peripheral areas with an average of 70 new cases a week in the whole operational zone. It is the result of the community commitment to accept and participate in the actions of the response and a certain free movement of the response teams in the city. This is not only because the Ebola response teams have improved their service, but also because the population especially the youth understood the risk and started collaborating with the Ebola outbreak teams, even if a few remain resistant.

The expectation of the local coordination teams is to end the epidemic as soon as possible. With the efforts of everyone, everywhere, all partners can start to think about development projects post the Ebola epidemic.

"Chagas Disease at the U.S/Mexico Border"
Posted on Friday, May 24, 2019

By Dr. Sarah Hamer and Alyssa Meyers

Researchers at the Texas A&M College of Veterinary Medicine & Biomedical Sciences (CVM), in collaboration with the Institute for Infectious Animal Diseases (IIAD) at Texas A&M, have received funding for the third phase of research from the U.S. Department of Homeland Security (DHS) to secure the health of dogs working at the United States and Mexico border.

With this new wave of funding, Dr. Sarah Hamer, an associate professor in the CVM’s Department of Veterinary Integrative Biosciences (VIBS); Alyssa Meyers, one of Hamer’s doctoral students; and a team of researchers are taking an in-depth look at dogs working along the U.S.-Mexico border to further study the impending health implications of Chagas disease and the effect this disease has on the canines’ ability to work.

What is Chagas disease?

Chagas disease, caused by the protozoan parasite Trypanosoma cruzi, is transmitted through kissing bugs, or cone-nose bugs, and can cause acute or chronic heart disease or death in dogs and humans.

While Chagas disease has long been known in Central and South America, there is now increasing awareness for the disease in the southern United States where kissing bugs occur.

Why study Chagas disease in dogs?

In South America dogs serve as both domestic reservoirs and as sentinels for human infection-the extent to which they play these roles in the U.S. is not yet understood and more research is needed. However, a positive dog without a travel history indicates that transmission is taking place in that environment and there is a potential risk for human exposure. “Though Chagas is an emerging disease that we know is in Texas and know can infect dogs and people, we don’t know the full extent of the impact or spread of the disease,” said IIAD director Melissa Berquist, Ph.D. IIAD is a U.S. Department of Homeland Security (DHS) Science and Technology Center of Excellence and a unit of Texas A&M AgriLife.

“By gaining a better understanding of the geographic areas where dogs are becoming exposed and the prevalence of exposure, we are gaining critical information for health management and vector control programs in order to decrease transmission within the DHS human and canine workforce,” she said.

Why study the DHS dogs?

“The DHS maintains more than 3,000 working dogs across the country, including the security dogs at the airports, customs and border protection dogs, Coast Guard dogs, federal protective service dogs, and secret service dogs,” Meyers explained. “These are highly valuable dogs, often selected for their drive and pedigree, and, unfortunately, our initial research found that up to 18 percent of the working dogs along the Texas-Mexico border were positive for exposure to T. cruzi, the Chagas parasite.”

The team then expanded their study to look at government working dogs across the U.S., not just on the southern border. This expanded study found that approximately 7 percent of the dogs were exposed to the parasite that causes Chagas disease. Understanding the epidemiology of T. cruzi infection in the DHS dogs could raise awareness among veterinarians regarding T. cruzi infection throughout the U.S. Furthermore, understanding the distribution and risk factors for zoonotic parasite infection in natural populations of dogs could potentially be informative for public health.

So dogs in the U.S. are widely infected-what’s next?

After this eye-opening discovery, Hamer decided to narrow the research on the long-lasting health implications of Chagas disease in these working dogs.

“It’s pretty exciting work because we’re intercepting these border patrol dogs while they’re working,” Hamer said. “We take a blood sample, monitor their heart, have them run on a treadmill, and we want to put on a Fit Bark—which is like a Fit Bit, but for dogs—all while they’re still working and doing their normal jobs.”

Because there is no vaccination to prevent Chagas disease in humans or animals, and approved treatment is limited, Meyers said the team also plans to use this grant to focus on what can be done to control the kissing bugs and prevent transmission. “There is an incomplete understanding of vector-host interactions that impedes vector control efforts, so if we better understand the behavior and life history of the bug, we can better prevent transmission.”

What type of vector control can be used?

“Vector control includes things like clearing brush where kissing bugs can dwell from around kennels and houses, minimizing the use of light at night because kissing bugs are drawn to light, and securing access to kennels, to prevent bugs from getting in,” Meyers said.

Although securing the kennels may seem like an easy fix, it can be a costly and challenging intervention for these facilities, which house dozens of dogs, according to Hamer.

What about other vector-borne diseases?

Along with studying Chagas disease, Hamer’s team will be using the grant to study other vector-borne disease- including those spread by ticks and mosquitoes- that may impact these working dogs.

“Because these working dogs spend lots of time outside where they may be exposed to vectors, they may provide a sensitive indication of the different vector-borne infections across the landscape that are not only important for dog health, but also human health,” Hamer said. “Our studies will have an increased focus on what we can do to ensure these animals remain healthy. We’re excited that Texas A&M University is really helping secure the health of these important animals that are on the frontlines of security for our country.”

"Eating a Earth: A Risk Factor For Or Protective Behavior Against Infection?"

Posted on Tuesday, Apr 23, 2019

By Joshua Miller, Northwestern University
Photo by Dr. Sera Young
From birth, we are taught to avoid dirt. And with good reason: soil can be a vector for geohelminths (i.e. intestinal parasites), pathogenic microbes, and heavy metals. So we wash our hands after working outside and rinse our produce before serving it. But digging deeper into the topic of geophagy — the craving and purposeful consumption of earth —and to “clean” clay-rich earths beneath surface soils, reveals that eating “dirt” may, at times, be beneficial.
Hippocrates first described geophagy over 2500 years ago, but the practice is not confined to antiquity. Among humans, the practice is most common among adolescents and pregnant females, from the southern United States to abroad. In some studies, more than 70% of pregnant females attending antenatal clinics report eating earth. The practice has also been widely documented across the animal kingdom; over 200 species of terrestrial vertebrates and arthropods have been reported as deliberately consuming earth. Yet despite its ubiquity, the causes and consequences of geophagy remain largely unknown.
A leading hypothesis is that earth serves as a micronutrient supplement. When individuals are unable to obtain essential nutrients, it seems logical that they may turn to non-food substances, including, perhaps most conveniently, the earth beneath their feet. Indeed, geophagy is strongly and consistently associated with anemia, a condition that most commonly results from a shortage of iron in the body. But molecular examination reveals that craved earths are low in bioavailable iron (i.e. iron that can be taken up for use by the body) and can even impede absorption of iron from dietary sources.
A second, less intuitive hypothesis is that geophagy is an adaptive behavior that protects against infection. Interestingly, geophagy is most prevalent among populations with developing or attenuated immune systems (children and pregnant women, respectively). Geophagy has also been documented among patients undergoing renal dialysis and people living with HIV. The behavior is also more common in moist tropical climates, where the burden of infectious disease is highest.
While some soils can cause disease, especially surface soil layers that are rich in organic material, geophagists often describe cravings for “clean dirt”. Preferred clay-rich earths have few or no geohelminth eggs and have the potential to be protective by adsorbing harmful toxins or pathogens, serving as a mud mask for the gut. Additionally, earths may restrict the uptake of minerals and thereby starve pathogens — a process known as nutritional immunity.
Clays have been heralded as natural medicaments long before recent in vitro studies have confirmed their ability to bind bacteria, fungi, and viruses. In ancient Greece, for instance, stamped clays called “terra sigillata” were worth their weight in gold and praised for their purported health benefits; these clay tablets were often prescribed as antidotes for ingested poisons. Around the globe, many communities continue to use clays when preparing foods that contain harmful, and often unpalatable, phytochemicals; the clay binds the toxic substances and renders them safe for consumption.
There is ultimately limited information that can conclusively be stated about geophagy. Almost all studies to date have been cross-sectional, prohibiting assessments of causality. Very little is also known about the cellular and chemical processes that underpin geophagy. Future studies should explore if increased inflammation is correlated with geophagy.
Field-ready tools for measuring the parasitological, microbial, and elemental profiles of geophagic earths could help consumers and practitioners balance the risks and benefits of geophagy more effectively and efficiently. Such information could help determine if we are walking on one of our best treatments against infection.

"Peter Hotez: It's Time for Scientists to Speak Up for Science"
Posted on Friday, Mar 29, 2019

This article originally appeared in Global Health NOW. Global Health Now, published by the Johns Hopkins Bloomberg School of Public Health, is a news website and free weekday email of essential global health news and views.

Originally published November 6, 2018
By Brian W. Simpson, Editor-In-Chief
Photo by Brian W. Simpson

HOUSTON – Peter Hotez has 2 words for his fellow scientists: Speak up.
A venerable vaccine researcher and dean of the National School of Tropical Medicine at Baylor College of Medicine, Hotez says he and other scientists of his generation were taught to do science and avoid speaking to the media and the public.
The “cone of silence culture,” as he calls it, hasn’t worked out very well. With adroit social media messaging, anti-science movements—including those that undermine the value of vaccines—have been able to seize the public discourse.
Hotez says he is uniquely positioned to respond: He’s a vaccine scientist, a pediatrician-scientist and an autism dad. His latest defense of science is a new book, “Vaccines Did Not Cause Rachel’s Autism” (Johns Hopkins University Press). The book seeks to clear some people’s muddied perspectives on autism and vaccines while also sharing his journey with his daughter Rachel.
Tell us about your book.
It is a science book that talks about the science showing there’s no link between vaccines and autism, what autism is and how it’s a developmental pathway that begins prenatally. But then it all changes with a very personal story because I’m also an autism dad. It explains what it’s like to be a parent of an adult with autism and associated intellectual disabilities.
You’ve taken on people who are against vaccines. How has that gone?
So far, it’s pretty rocky. The anti-vaccine groups are pretty aggressive and they’re very effective in their use of the Internet and social media and … cyber bullying. It’s a tough one. In some ways this is my toughest battle yet.
What specifically have you faced?
Well, they make up things. They always say I’m a shill for industry. Even though I’ve never taken any money from the vaccine industry. My favorite is when they say I’m secretly making millions of dollars off of vaccines for schistosomiasis and hookworm and Chagas disease and leishmaniasis, to which my wife says, “If only. We could finally pay off our mortgage.”
Did you anticipate being a target like this?
I knew they are pretty aggressive. I saw how they beat up some good colleagues of mine on vaccines, but I felt that I had a unique voice as both a vaccine scientist, a pediatrician-scientist and as an autism dad. Who else could do it? So I felt in some ways chosen to do this. And that’s why I do it.
Do you understand the motivation for the people who are against vaccines? What is that—
I ask this all the time. What’s driving this and who’s paying for this garbage? I mean, there’s money behind it. There’s no question about it. Where is it coming from? I think we need good investigative journalist to kind of really figure this out.
Do you have any sense of how things are trending—in a positive way or are we still in a trough where things are going to be more difficult for science?
Well, I think it’s a good news, bad news, bad news story. We’ve seen now dramatic declines in deaths globally from vaccine preventable diseases. Big reductions in deaths from measles and pertussis and tetanus and haemophilus influenza type B or near eradication of polio. So that’s an amazing success story.
But while that’s going on … we have the unraveling of those successes in Europe and North America. And we’ve got some clear trends. We’ve got this dramatic return of measles across Europe. Big drops in vaccine coverage, especially in the western parts of the United States. Tens of thousands of people dying of influenza who didn’t need to die of influenza. Ridiculously low uptake of the HPV vaccine for cervical cancer---unnecessarily subjecting a generation of girls and women in the US to cervical cancer. This is terrible.
And what’s interesting is the general silence on the pro-vaccine side. We’re not hearing from the CDC. We’re not hearing from the Surgeon General. We’re not hearing from the major societies. So that’s one of the reasons I wrote the book. I felt there needed to be a voice saying, “No mas, we’ve got to stop this thing.”
Is it going to take a vaccine-preventable epidemic before the anti-vaccine side really appreciates their value?
It’s going to take a big measles outbreak with measles deaths to really wake people up and to do something about it. And even then, in Europe it really has not stimulated a lot of action. And it’s very frustrating because you can see this train coming 2 miles down the tracks.
And it probably will be measles because it’s so easily transmitted?
Measles tends to be the often the first breakthrough infection you see because it’s so highly transmissible. It’s one of the most infectious agents we know about. It has a reproductive number of 12 to 18. So a single individual gets measles, 12 to 18 other unvaccinated individuals get it.
Should scientists counter anti-vaccine messages with similarly powerful, boiled-down messages?
You raise a very good point. So, boiled down messages, that’s actually a very profound question because one of the things that I have done in this book, which is really taking me out of my comfort zone, is I speak and I write in simple declarative sentences. Vaccines don’t cause autism. And that’s not how we speak [as] scientists.
If you look for instance the IOM report … in 2012 or 2013. They will say something like, “Well, the preponderance of evidence today cannot show any clear link between vaccines and autism.”
As scientists, we understand what that means, but the general public says, “What are they covering up? What do they really mean?” I try to close the door on that by speaking in straightforward sentences. Vaccines don’t cause autism. Here’s why. Again, that’s not the way that we often speak, but maybe we should. Maybe this is part of the training we have to give to young scientists, is how to craft messages, how to speak to the public in a way that they’ll understand.
But scientists are often very cautious, very aware of nuance and say: “Well we know this in this particular situation, but we don’t want to generalize beyond that.”
We don’t like to go out over our skis in terms of the evidence. That’s our training too. And I think when we speak to each other as scientists, that still holds. But I think we’re losing the public in our ability to message what we’re doing.
What would your message be to your fellow scientists? Do you see it as the responsibility of being a scientist to be a public voice for science?
I think if you have the capability and the drive, I think there is a component of responsibility to it because we’ve now seen the consequences of not directly engaging the public. For the first time now, we’re starting to see people dying because they’re not being vaccinated for phony reasons.
What do you tell your students?
It’s funny you ask because I have a new paper out in PLOS Biology called “Crafting your scientist brand” for a sort of how to, how to do it. When I talk to [scientists and students] about engaging the public … I’ll usually have a line of students coming up to me afterwards basically saying, “Okay, we’re all in. We get it.” Which is really nice. The hard part is we don’t have straightforward career pathways for how you get involved with public engagement in science. There’s no real roadmap. Even for me, it’s sort of seat of the pants learning. I was never formally trained in policy or advocacy and learning it as I go.
Do you see that as an important requirement going forward to educate young scientists in communications?
I think it hasn’t totally crept into the DNA of our training yet, but I’m hoping that will change. I think it’s necessary because things are not getting any better. So as we’re speaking today, the CDC has just released information that 80,000 people died in this year’s flu epidemic. Terrible year, including more than 180 children and most of those children we now know were not vaccinated, even though the recommendation was that they get vaccinated. So the anti-vaxxers won. It is a Pyrrhic victory, but they won, and tens of thousands of people died who didn’t have to die.
People are now starting to die from anti-science movements, and there’s no one else who can do this. It falls on the scientists to speak up. And that’s why I wrote the new book.

Ed. Note: This interviewed has been edited for clarity and length.

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