Global & Disaster Medicine

Archive for the ‘Documents’ Category

French Republic Assessment of Chemical Attack in Douma, Syria April 2018.

NY Times

National assessment

Chemical attack of 7 April 2018 (Douma, Eastern Ghouta, Syria)

Syria’s clandestine chemical weapons programme

April 14, 2018

This document is based on technical analyses of open source information and declassified intelligence obtained by French services.


Following the Syrian regime’s resumption of its military offensive, as well as high levels of air force activity over the town of Douma in Eastern Ghouta, two new cases of toxic agents employment were spontaneously reported by civil society and local and international media from the late afternoon of 7 April. Non-governmental medical organizations active in Ghouta (the Syrian American Medical Society and the Union of Medical Care and Relief Organizations), whose information is generally reliable, publicly stated that strikes had targeted in particular local medical infrastructure on 6 and 7 April.

A massive influx of patients in health centres in Eastern Ghouta (at the very least 100 people) presenting symptoms consistent with exposure to a chemical agent was observed and documented during the early evening. In total, several dozens of people, more than forty according to several sources, are thought to have died from exposure to a chemical substance.

The information collected by France forms a body of evidence that is sufficient to attribute responsibility for the chemical attacks of 7 April to the Syrian regime.

1. – Several chemical attacks took place at Douma on 7 April 2018.

The French services analysed the testimonies, photos and videos that spontaneously appeared on specialized websites, in the press and on social media in the hours and days following the attack. Testimonies obtained by the French services were also analysed. After examining the videos and images of victims published online, they were able to conclude with a high degree of confidence that the vast majority are recent and not fabricated. The spontaneous circulation of these images across all social networks confirms that they were not video montages or recycled images. Lastly, some of the entities that published this information are generally considered reliable.

French experts analysed the symptoms identifiable in the images and videos that were made public. These images and videos were taken either in enclosed areas in a building where around 15 people died, or in local hospitals that received contaminated patients. These symptoms can be described as follows (cf. annexed images):

– Suffocation, asphyxia or breathing difficulties, – Mentions of a strong chlorine odour and presence of green smoke in affected areas, – Hypersalivation and hypersecretions (particularly oral and nasal), – Cyanosis, – Skin burns and corneal burns.


No deaths from mechanical injuries were visible. All of these symptoms are characteristic of a chemical weapons attack, particularly choking agents and organophosphorus agents or hydrocyanic acid. Furthermore, the apparent use of bronchodilators by the medical services observed in videos reinforces the hypothesis of intoxication by choking agents.

2. – Given in particular ongoing military operations in Eastern Ghouta around 7 April, we assess with a high degree of confidence that the Syrian regime holds responsibility.

Reliable intelligence indicates that Syrian military officials have coordinated what appears to be the use of chemical weapons containing chlorine on Douma, on April 7.

The attack of 7 April 2018 took place as part of a wider military offensive carried out by the regime on the Eastern Ghouta region. Launched in February 2018, this offensive has now enabled Damascus to regain control of the entire enclave.

As a reminder, the Russian military forces active in Syria enable the regime to enjoy unquestionable air superiority, giving it the total military freedom of action it needs for its indiscriminate offensives on urban areas.

The tactic adopted by pro-regime forces involved separating the various groups (Ahrar al-Sham, Faylaq al-Rahman, and Jaysh al-Islam) in order to focus their efforts and obtain negotiated surrender agreements. The three main armed groups therefore began separate negotiations with the regime and Russia. The first two groups (Ahrar al-Sham and Faylaq al-Rahman) concluded agreements that resulted in the evacuation of nearly 15,000 fighters and their families. During this first phase, the Syrian regime’s political and military strategy consisted in alternating indiscriminate military offensives against local populations, which sometimes included the use of chlorine, and pauses in operations for negotiations.

Negotiations with Jaysh al-Islam began in March but were not fully conclusive. On 4 April, part of the Jaysh al-Islam group (around one quarter of the group according to estimates) accepted the surrender agreement and fighters and their families were sent to Idlib (approximately 4,000 people, with families). However, between 4,500 and 5,500 Jaysh al-Islam fighters, mostly located in Douma, refused the terms of negotiation. As a result, from 6 April onwards, the Syrian regime, with support from Russian forces, resumed its intensive bombing of the area, ending a pause in ground and aerial operations that had been observed since negotiations began in mid-March. This was the context for the chemical strikes analysed in this document.

Given this context, the Syrian regime’s use of chemical weapons makes sense from both the military and strategic points of view:

 Tactically speaking, this type of ammunition is used to flush out enemy fighters sheltering in homes and engage in urban combat in conditions that are more

favourable to the regime. It accelerates victory and has a multiplier effect that helps speed up the capitulation of the last bastion of armed groups.

 Strategically speaking, chemical weapons and particularly chlorine, documented in Eastern Ghouta since early 2018, are especially used to punish civilian populations present in zones held by fighters opposed to the Syrian regime and to create a climate of terror and panic that encourages them to surrender. As the war is not over for the regime, it uses these indiscriminate strikes to show that resistance is futile and pave the way for capturing these last pockets of armed resistance.

 Since 2012, the Syrian forces have repeatedly used the same pattern of military tactics: toxic chemicals are mainly used during wider urban offensives, as was the case in late 2016 during the recapture of Aleppo, where chlorine weapons were regularly used in conjunction with traditional weapons. The zones targeted, such as Eastern Ghouta, are all major military objectives for Damascus.

3. – The French services have no information to support the theory whereby the armed groups in Ghouta would have sought to acquire or have possessed chemical weapons.

The French services also assess that a manipulation of the images circulated massively from Saturday, 7 April is not credible, in part because the groups present in Ghouta do not have the resources to carry out a communications operation on such a scale.


4. – The Syrian regime has conserved a clandestine chemical weapons programme since 2013.

The French services assess that Syria did not declare all of its stockpiles and capacities to the Organisation for the Prohibition of Chemical Weapons (OPCW) during its late, half-hearted accession to the Chemical Weapons Convention (CWC) in October 2013.

Syria omitted, notably, to declare many of the activities of its Scientific Studies and Research Centre (SSRC). Only recently has it accepted to declare certain SSRC activities under the Chemical Weapons Convention (CWC), but not, however, all of them. Initially, it also failed to declare the sites at Barzeh and Jemraya, eventually doing so in 2018.

The French services assess that four questions asked of the Syrian regime by the OPCW and which have remained unanswered require particular attention, particularly in the context of these latest cases of the use of chemical weapons in Syria: – possible remaining stocks of yperite (mustard gas) and DF (a sarin precursor); – undeclared chemical weapons of small calibre which may have been used on several occasions, including during the attack on Khan Sheikhoun in April 2017;

– signs of the presence of VX and sarin on production and loading sites; – signs of the presence of chemical agents that have never been declared, including nitrogen mustard, lewisite, soman and VX.

Since 2014, the OPCW Fact-Finding Mission (FFM) has published several reports confirming the use of chemical weapons against civilians in Syria. The UN-OPCW Joint Investigation Mechanism (JIM) on chemical weapons attacks has investigated nine occasions when they have allegedly been used. In its August and October 2016 reports, the JIM attributed three cases of the use of chlorine to the Damascus regime and one case of the use of yperite to Daesh, but none to any Syrian armed group.

5. – A series of chemical attacks has taken place in Syria since 4 April 2017

A French national assessment published on 26 April 2017 following the Khan Sheikhoun attack listed all the chemical attacks in Syria since 2012, along with the assessment of their probability according to French services. This attack, carried out in two phases, at Latamneh on 30 March, and then at Khan Sheikhoun with sarin gas on 4 April, led to the death of more than 80 civilians. The French authorities considered at the time that it was very likely that the Syrian armed and security forces held responsibility for the attack.

The French services have identified 44 allegations of the use of chemical weapons and toxic agents since 4 April 2017, the date of the sarin attack on Khan Sheikhoun. Of these 44 allegations, the French services consider that the evidence collected around 11 of the attacks gave reason to assess they were of a chemical nature. Chlorine is believed to have been used in most cases, while the services also believe a neurotoxic agent was used at Harasta on 18 November 2017.

In this context, a considerable rise in cases of use can be noted since the non-renewal of the mechanism of the UN-OPCW Joint Investigation Mechanism (JIM) in November 2017 because of Russia’s veto at the UN Security Council. A considerable increase in chlorine attacks since the beginning of the offensive on Eastern Ghouta has also been clearly observed and proven. A series of attacks preceded the major attack of 7 April 2018, as part of a wider offensive (at least 8 chlorine attacks in Douma, Shayfounia and Hamouria).


These facts need to be considered in the light of a chemical warfare modus operandi of the Syrian regime that has been well documented since the attacks on Eastern Ghouta on 21 August 2013 and on Khan Sheikhoun on 4 April 2017. As part of a continuous increase in violence employed against civilians in enclaves refusing the regime’s authority, and in violation of its international obligations despite clear warnings from UN Security Council and OPCW members, Damascus seeks to seize a tactical military advantage locally, and above all to terrorize populations in order to break down all remaining resistance. It can be noted that, since the attacks of

7 April 2018, the group Jaysh al-Islam has negotiated its departure from Douma with the regime and Russia, demonstrating the success of this tactic.

On the basis of this overall assessment and on the intelligence collected by our services, and in the absence to date of chemical samples analysed by our own laboratories, France therefore considers (i) that, beyond possible doubt, a chemical attack was carried out against civilians at Douma on 7 April 2018; and (ii) that there is no plausible scenario other than that of an attack by Syrian armed forces as part of a wider offensive in the Eastern Ghouta enclave. The Syrian armed and security forces are also considered to be responsible for other actions in the region as part of this same offensive in 2017 and 2018. Russia has undeniably provided active military support to the operations to seize back Ghouta. It has, moreover, provided constant political cover to the Syrian regime over the employment of chemical weapons, both at the UN Security Council and at the OPCW, despite conclusions to the contrary by the JIM.

This assessment will be updated as we collect new information.

Emergency Trauma Response to the Mosul Offensive, 2016-2017

Fox, H., Stoddard, A. & Davidoff, J. (2018). Emergency trauma response to the Mosul offensive, 2016-2017: A review of issues and challenges. Humanitarian Outcomes, March.

“…..Despite certain weaknesses and limitations, the WHO-coordinated response succeeded in implementing a
large-scale, military-style referral chain system in highly difficult conditions and unquestionably saved lives.
An independent analysis of the data performed by a research team at John Hopkins Centre for Humanitarian
Health estimates that the WHO-coordinated trauma referral pathway saved between 1,500 and 1,800 lives –
approximately 600-1,330 civilians and the remaining majority combatants.

The total number of people treated is impossible to independently verify. WHO reporting cites that as of 7 August
2017, ‘some 20,449 people from Mosul city were referred through the established trauma pathways’.  But these
figures include patients being counted multiple times as they passed through the referral pathway. The Iraqi
Department of Health estimated that 10,000 to 12,000 ‘medical activities’ were performed…….Despite these constraints, between October 2016 and November 2018, MSF performed 20,334 emergency room
consultations (of which 4,135 were ‘war trauma’3 cases and 1,594 were ‘red’ cases4) and 31,242 primary health care
consultations. These emergency room and primary health consultations resulted in 3,601 surgical interventions,
1,178 deliveries and 2,647 inpatient admissions……”

 case study by Johns Hopkins. :  Document

IRIN opinion

Impact of Armed Conflict on Healthcare in Afghanistan: UN Report

Afghanistan and the Protection of Civilians :  Document

“…..In 2017, UNAMA documented 75 incidents targeting and/or impacting healthcare and healthcare workers that caused 65 civilian casualties (31 deaths and 34 injured) compared to 120 incidents in 2016 that resulted in 23 civilian casualties (10 deaths and 13 injured).

Most of the civilian casualties (26 deaths and 22 injured) in 2017 occurred in the context of a complex attack by Anti-Government Elements on the Mohammad Sardar Daud Khan Hospital in Kabul city on 8 March.

Threats, intimidation, harassment and abduction of medical personnel comprised the majority of incidents in 2017.

UNAMA recorded the targeted killing or attempted targeted killing of five healthcare professionals (three deaths and two injured) by Anti-Government Elements in 2017. In one case, on 10 October, in Tera Zayi district, Khost province, Anti-Government Elements stopped a healthcare professional from a mobile team while he was riding a motorcycle, opened fire and killed him.

Throughout 2017, Anti-Government Elements abducted 22 healthcare workers in 11 incidents, killing one of them. The other healthcare workers were released unharmed, mostly without ransom, often following the intervention of local elders. In 2017, Anti-Government Elements continued to target ambulances – UNAMA recorded five such attacks, all during the first half of the year.  For example, on 26 April, in Bagram district, Parwan province, Anti-Government Elements detonated a remote-controlled IED against an ambulance driving to the site of a murder, injuring five civilians, including a forensic doctor, two investigators, and two child bystanders.

UNAMA also recorded five incidents of intentional damage to medical facilities by AntiGovernment Elements, including one case in Badghis province, on 20 September, where AntiGovernment Elements fired rocket-propelled grenades at a clinic under construction, which resulted in its destruction and caused three civilian casualties (one death and two injured) in a nearby private house.

UNAMA documented the temporary closure of at least 147 health facilities in 2017, following threats issued by Anti-Government Elements, compared to 20 such closures in 2016. These closures ranged from several hours, with partial continuation of services, to several months of complete interruption of services, and negatively affected access to healthcare for numerous people in these areas…..”


Disaster Telemedicine

MedPage “…..I witnessed the potential first-hand in Puerto Rico after Maria. Less than two weeks after arriving at a location with no potable water and intermittent electrical power, my team had access to a live video link to an academic medical center in the mainland U.S. A specially outfitted laptop and an on-site satellite dish, along with a temperamental but functional generator, meant that my patients and I could communicate with specialists like pediatricians and psychiatrists — vital caregivers that were scarce on the island and unavailable to my team otherwise. We also faced some challenges: a glitchy connection, and a feeling that our tele-resources sometimes didn’t really match our real patients’ needs. Was it worth it? Mostly……”



Am J Disaster Med. 2014 Winter;9(1):25-37. doi: 10.5055/ajdm.2014.0139.
Telemedicine for disaster management: can it transform chaos into an organized, structured care from the distance?



Telemedicine and advanced technologies that ensure telepresence have become common practice and are an effective way of providing healthcare services.


The authors conducted a traditional narrative review of English literature through search engines (Medline, Pub Med, Embase, and Science Direct) using mesh terms “telemedicine,” “telepresence,” “earthquake,” “disaster,” “natural disaster,” and “man-made disaster” published between January 1, 1980 and September 30, 2013. For our analysis, only published studies were selected when telemedicine or telepresence was reported for disaster management, both in real life and in mock and simulation situations. Original articles, clinical trials, case presentations, and review articles were considered. Books and book chapters were used as well. Data from the International Disaster Database were included in the review to provide a sense of worldwide disaster occurrence. Symposia and other meetings were searched and used when available.


Between January 1980 and September 2013, 17,565 disasters recorded. During this study period, 878 articles, chapters, books, and presentations were reported. Of these, only 88 articles and books fulfilled our selection criteria. Six articles described the effectiveness of telemedicine in mock simulations and disaster drills, and 63 presented the need and discussed how telemedicine would be beneficial in disaster response. Only 19 articles provided examples of effective use of telemedicine in disaster response. However, these studies demonstrated telemedicine as a valuable tool for communication between front-line humanitarian aid workers and expert physicians at remote locations.


Telemedicine has not been used thus in the management of disasters, despite its great potential. There is an acute need for establishing telemedicine programs in high risk areas for disasters, so that when these disasters strike, existing telemedicine networks can be used, rather than attempting to bring solutions into a chaotic situation postevent

A new report from the Johns Hopkins Center for Health Security said that while America is well prepared to handle small health emergencies (think tornadoes), it is poorly equipped to handle large-scale natural disasters or complex health events, including the next pandemic.

JHCHS Press Release

By Nick Alexopulos | Feb. 22, 2018
Full report (PDF)

The health sector in the United States would be far better positioned to manage medical care needs during emergencies of any scale by empowering existing healthcare coalitions to connect community resilience efforts with a network of hospitals equipped to handle disasters, according to a new report by the Johns Hopkins Center for Health Security.

The report, “A Framework for Healthcare Disaster Resilience: A View to the Future,” was released at a February 22 event at the National Press Club.

A Framework for Healthcare Disaster Resilience: A View to the Future

“We wondered what an optimal system would look like and how we would get there,” said Eric Toner, MD, a senior scholar at the Center and principal investigator on the report. “Change is needed, but the change should be evolutionary, not revolutionary. We need to build on the resources we already have.”

Toner’s coauthors on the report are Center colleagues Monica Schoch-Spana, PhD, Richard Waldhorn, MD, Matthew Shearer, MPH, and Tom Inglesby, MD. The team first identified four distinct categories of disasters that could cause significant illness or injury, and for which preparedness gaps likely exist due to differing operational challenges and resource needs. A subsequent gap analysis confirmed their theory: While the US health sector is reasonably well prepared for relatively small mass injury/illness events that happen frequently (e.g., tornadoes, local disease outbreaks), it is less prepared for large-scale disasters (e.g., hurricanes) and complex mass casualty events (e.g., bombings) and poorly prepared for catastrophic health events (e.g., severe pandemics, large-scale bioterrorism).

These gaps, the authors say, exist as a result of the absence of strategies above and beyond the traditional all-hazards approach to improving US health sector preparedness. The authors define the US health sector as all entities and personnel that are involved in people’s health, combined with the community-based organizations that support these entities and represent the patients who receive services from them. This network’s incident-specific response actions and capabilities vary widely across the four categories of disasters.

The authors offer four recommendations for closing preparedness gaps unique to the US health sector:

Build a Culture of Resilience: Launch a new federal program that encourages and incentivizes local grassroots and community-based organizations to become more involved in efforts to enhance the disaster resilience of the local health sector. This Culture of Resilience program would engage organizations traditionally not involved in health sector preparedness.

Create a network of disaster centers of excellence: Connect geographically distributed, large academic medical centers and designate them Disaster Resource Hospitals by setting rigorous standards, providing direct funding, and requiring accountability. These hospitals would be a source of remote, real-time clinical expertise, continuing education and training, and expertise for public health officials, among other benefits.

Increase support for healthcare coalitions (HCCs): Already successful healthcare coalitions comprising well-prepared hospitals, health departments, EMS providers, and emergency management need additional funding to engage other organizations inside the health sector (e.g., nursing homes) and outside the health sector (e.g., faith-based community groups) in preparedness work. HCC-led collaboration would then help integrate disaster resource hospital capabilities into preparedness and response for the overall coalition, and link community resilience efforts back to disaster research hospitals.

Designate a federal coordinator for catastrophic health event preparedness: Within the Office of the Assistant Secretary for Preparedness and Response (ASPR) in the US Department of Health and Human Services, dedicate a group responsible only for preparing the nation for catastrophic health events. This group would coordinate existing decentralized healthcare preparedness initiatives in ASPR and provide a vision for strengthening preparedness in the future, with an increased focus on resilience.

“It is now widely recognized that resilience of communities and systems should be the goal rather than just preparedness,” the authors wrote in the report. “Resilient communities seek to resist the impact of disasters, recover promptly to normal operational capacity, and learn how better to withstand future events.”

The report concludes with policy requirements for each of these recommendations. There is opportunity for some of the requirements to be incorporated into the Pandemic and All-Hazards Preparedness Act reauthorization this year.

“There needs to be more focus at the federal level, particularly on catastrophic health events,” Toner said to an audience of more than 40 people in the health security policy community in attendance at the Press Club.

Guest speakers at the event included Luciana Borio, MD, director of global health security and biological threats for the White House National Security Council; Sally Phillips, PhD, deputy assistant secretary for policy in the Office of the Assistant Secretary for Preparedness and Response at the US Department of Health and Human Services; and Linda Langston, director of strategic relations at the National Association of Counties.

To inform their work, the project team reviewed five years of published literature and conducted a series of working group meetings, a focus group, and interviews with more than 40 subject matter experts and thought leaders.

This project was funded by the Robert Wood Johnson Foundation.


The World Resources Institute: 33 countries projected to face extremely high water stress (i.e. shortage of fresh water) in 2040.

NY Times

The Role of Water Stress in Instability and Conflict : Document



Study some ferrets inoculated intranasally with 1918 H1N1 virus and see what happens…..

1918 Pandemic research article

1918 H1N1 influenza virus replicates and induces pro-inflammatory cytokine responses in extra-respiratory tissues of ferrets

Emmie de Wit
Laboratory of Virology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, United States of America
Emmie de Wit: 903 South 4th Street, Hamilton, MT 59840, USA; phone: +1-406-375-7490; fax: +1-406-375-9620;
“…..Evidence for active virus replication, as indicated by the detection of nucleoprotein by immunohistochemistry, was observed in the respiratory tract, peripheral and central nervous system, and liver. Pro-inflammatory cytokines were upregulated in respiratory tissues, olfactory bulb, spinal cord, liver, heart and pancreas…..”
Corresponding authors: Debby van Riel: P.O. Box 2040, Ee1716, 3000 CA Rotterdam, The Netherlands; phone +31 10 704 4069; fax: +31 10 704 4760;
The Journal of Infectious Diseases, jiy003,

What is the PHEMCE?

The PHEMCE is an interagency coordinating body led by the HHS Assistant Secretary for Preparedness and Response, comprising the Centers for Disease Control and Prevention, the National Institutes of Health, the Food and Drug Administration, and interagency partners at the Departments of Defense, Veterans Affairs, Homeland Security, and Agriculture. It coordinates the development, acquisition, stockpiling, and recommendations for use of medical products that we need to effectively respond to a variety of high consequence public health emergencies, whether naturally occurring or intentional.



The 2017-2018 Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) Strategy and Implementation Plan (SIP) describes the priorities that the U.S. Department of Health and Human Services (HHS), in collaboration with its interagency partners, will implement over the next five years. This strategy updates the 2016 PHEMCE SIP and fulfills the annual requirement established by Section 2811(d) of the Public Health Service (PHS) Act, as amended by the Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA). The annual PHEMCE SIP provides the blueprint the Enterprise will use to enhance national health security through the procurement and effective use of medical countermeasures (MCM). Starting with this iteration of the SIP, the PHEMCE is retitling its SIP to reflect a more forward-focused strategic document by referring to the year the PHEMCE developed it as well as the following year. For example, the PHEMCE developed this SIP in 2017; therefore, it is the 2017-2018 PHEMCE SIP. The PHEMCE examines the SIP goals and objectives annually by taking into consideration the progress achieved and the remaining strategic gaps in MCM preparedness. During the development of the 20172018 PHEMCE SIP, the PHEMCE examined the goals and objectives articulated in the 2016 PHEMCE SIP and determined that no changes were necessary at this time.

The streamlined 2017-2018 PHEMCE SIP provides:

1) a summary of the major recent accomplishments;

2) new activities;

3) updates to the activities from the 2016 PHEMCE SIP; and

4) specific information required annually under PAHPRA reporting mandates.

The 2016 PHEMCE SIP identified priority activities in the near-term (fiscal year (FY) 20172018), mid-term (FY 2019-2020), and long-term (FY 2021 and beyond) timeframes. The PHEMCE maintained these timeframes in the 2017-2018 PHEMCE SIP. The PHEMCE is still pursuing activities detailed in the 2016 PHEMCE SIP unless otherwise noted in this document. All activities described are contingent on available appropriations.


A review of a mobile mass shooting in Kalamazoo

Frank Straub, Ph.D., Brett Cowell, Jennifer Zeunik, and Ben Gorban. Managing the Response to a Mobile Mass Shooting. April 2017. Washington, DC: Police Foundation.

  • “…..The sequence of events that began Saturday afternoon with the suspect driving recklessly in and around the streets of Kalamazoo, ultimately ended with his arrest early Sunday morning. During that time, he allegedly shot eight people, killing six and severely wounding two, across three separate locations in and around the city…..”

Trust for America’s Health: “As a nation, we—year after year—fail to fully support public health and preparedness. If we don’t improve our baseline funding and capabilities, we’ll continue to be caught completely off-guard when hurricanes, wildfires, and infectious disease outbreaks hit.”


“…..the country does not invest enough to maintain strong, basic core capabilities for health security readiness and, instead, is in a continued state of inefficiently reacting with federal emergency supplemental funding packages each time a disaster strikes.

According to Ready or Not?, federal funding to support the base level of preparedness has been cut by more than half since 2002, which has eroded advancements and reduced the country’s capabilities…..

The report card is based on 10 key indicators of public health preparedness. Half of all states scored a 5 or lower (out of 10), with Alaska scoring the lowest (2), and Massachusetts and Rhode Island scoring the highest (9). Delaware, North Carolina, and Virginia each scored 8 out of 10. Florida received a 6.….

Some key findings include:

  • Just 19 states and Washington, D.C. increased or maintained funding for public health from Fiscal Year (FY) 2015-2016 to FY 2016-2017.
  • The primary source for state and local preparedness for health emergencies has been cut by about one-third (from $940 million in FY 2002 to $667 million in FY 2017) and hospital emergency preparedness funds have been cut in half ($514 million in FY 2003 to $254 million in FY 2017).
  • In 20 states and Washington, D.C. 70 percent or more of hospitals reported meeting Antibiotic Stewardship Program core elements in 2016.
  • Just 20 states vaccinated at least half of their population (ages 6 months and older) for the seasonal flu from Fall 2016 to Spring 2017—and no state was above 56 percent.
  • 47 state labs and Washington, D.C. provided biosafety training and/or provided information about biosafety training courses (July 1, 2016 to June 30, 2017).

The Ready or Not? report provides a series of recommendations that address many of the major gaps in emergency health preparedness, including:

  • Communities should maintain a key set of foundational capabilities and focus on performance outcomes in exchange for increased flexibility and reduced bureaucracy.
  • Ensuring stable, sufficient health emergency preparedness funding to maintain a standing set of core capabilities so they are ready when needed. In addition, a complementary Public Health Emergency Fund is needed to provide immediate surge funding for specific action for major emerging threats.
  • Strengthening and maintaining consistent support for global health security as an effective strategy for preventing and controlling health crises. Germs know no borders.
  • Innovating and modernizing infrastructure needs – including a more focused investment strategy to support science and technology upgrades that leverage recent breakthroughs and hold the promise of transforming the nation’s ability to promptly detect and contain disease outbreaks and respond to other health emergencies.
  • Recruiting and training a next generation public health workforce with expert scientific abilities to harness and use technological advances along with critical thinking and management skills to serve as Chief Health Strategist for a community.
  • Reconsidering health system preparedness for new threats and mass outbreaks.  Develop stronger coalitions and partnerships among providers, hospitals and healthcare facilities, insurance providers, pharmaceutical and health equipment businesses, emergency management and public health agencies.
  • Preventing the negative health consequences of climate change and weather-related threats. It is essential to build the capacity to anticipate, plan for and respond to climate-related events.
  • Prioritizing efforts to address one of the most serious threats to human health by expanding efforts to stop superbugs and antibiotic resistance. 
  • Improving rates of vaccinations for children and adults – which are one of the most effective public health tools against many infectious diseases.
  • Supporting a culture of resilience so all communities are better prepared to cope with and recover from emergencies, particularly focusing on those who are most vulnerable.   Sometimes the aftermath of an emergency situation may be more harmful than the initial event.  This must also include support for local organizations and small businesses to prepare for and to respond to emergencies…….”


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