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The Unintended Health Consequences of Globalization. Italo Subbarao DO,MBA Director Public Health Readiness Office Deputy Editor Journal of Disaster Medicine Center for Public Health Preparedness & Disaster Response. Why???...Ok What is Globalization.

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The Unintended Health Consequences of Globalization

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The Unintended Health Consequences of Globalization

Italo Subbarao DO,MBA

Director Public Health Readiness Office

Deputy Editor Journal of Disaster Medicine

Center for Public Health Preparedness

& Disaster Response

Why???...Ok What is Globalization

  • Globalization "is the closer integration of the countries and peoples of the world ...brought about by the enormous reduction of costs of transportation and communication, and the breaking down of artificial barriers to the flows of goods, services, capital, knowledge, and people across borders.”

    Joseph Stiglitz Noble Prize Economist

Globalization: The Flattening of the World

  • Global Economy

    • Dramatic Increases in Technological Efficiencies: Cheaper Goods and Services

      • Outsourcing: Radiologist doing evaluations from Australia

    • Increased Trade and Commerce

  • Communication

    • Virtual Communities (Shared Ideologies)

    • 24/7 News world

Globalization: Closing the Economic Gap between Developing and Developed Nations

The Rise of Asia in the Global Economy

Globalization’s Impact on Developing Countries…Too good to be true!!

  • Rapid Industrialization and Urbanization

    • Demand for Energy and Land

    • Profits maximized: No focus on standards and regulations

    • Demand for all populations to be involved in the “gold rush”

I thought globalization is good right???

Goal: Unintended Consequences of Globalization

  • Review Global Trends in Natural Disasters

  • Review the Health Impact of Climate Change

  • Review the Concern of Pandemic Influenza and Emerging Infections

  • Review the Risk of Global Terrorism

    • Case Study of the Virginia Tech Tragedy

Climate System

Greenhouse Effect

Global Warming

Carbon Dioxide10000 years before 2005

Methane10000 years before 2005

Nitrous Oxide10000 years before 2005

Greenhouse Gases

  • Carbon Dioxide 35% increase since industrial age

    • Combustion of Fossil Fuels

    • Deforestation

  • Methane 154% increase since industrial age

    • Animal (cattle and sheep) gas

  • Nitrous Oxide

  • Water Vapor

World Consumption

Climate Change Controversy

  • Nobody argues that the earth is getting warmer and that climate change is occurring.

  • Controversy is global warming part of the natural planetary cycle or does man have influence?

  • Other issue is whether curbing CO2 emissions now will have a real impact in the immediate future.

Curbing Carbon Emissions: No Easy Solution

  • Alternative Energy Non-Fossil Fuel Based

    • Wind, Solar, Nuclear

    • Ethanol Corn, Sugar Cane, Catalytic

    • Energy Efficiency

  • Carbon Emission Regulation: Carbon Tax

Kyoto Protocol: UN Agreement

  • Protocol signed by 167 countries: US and Australia notable exceptions

    • China and India have signed on

  • Cut greenhouse gas emissions by 5% less than 1990 emissions.

  • If unable can purchase carbon credits but are penalized in the future.

  • Treaty expires 2013

Unintended Consequences of Climate Change

Defining a Disaster

Risk = Hazard * Vulnerability

Phases in Disaster Preparedness


Societal Disruption

  • Infrastructure destruction

    • Hospitals

    • Primary Health Centers

    • Homes

    • Transportation

Criteria for a Natural Disaster

  • 10 or more people reported killed

  • 100 people reported affected

  • Declaration of a state of emergency

  • Call for international assistance


Natural Disasters

Comparative Review of Natural Disasters

Continental Comparisons

Mortality and Population Affected

Extreme Heat and Cold Waves: Populations susceptible

  • Elderly and Children

  • Those with Chronic Diseases

  • Lower Socioeconomic: Homeless

Climate Change???

What’s All The Hype About???

Infectious Disease and Globalization:

  • Urbanization (Developing Countries)

  • Overpopulation

  • Travel Projections

  • Climate Change Impact

Globalization and Urbanization:

  • 2006 UN Report: 1976 1/3rd of the population lived in cities

  • Today 50% of the worlds population lives in cities

  • Greatest growth is in developing countries: China and India

Overpopulation: Feed Me!!!

  • Pollution

  • Improper Waste Disposal

  • Depletion of Natural Resources

  • Overcrowding/ Slums: Mixing of Human and Animal populations

  • Increased Consumption

Travel projections until 2017

Influenza A

  • Orthomyxoviridae:

    • Single Stranded RNA Virus

  • Two proteins responsible for virulence

    • Hemagglutinin (HA) (1-16)

    • Neuraminadase (NA) (1-9)

  • Principal method of protection is seasonal immunization

    NA inhibitors are also efficacious

    Typical Seasonal Flu occurs during the winter season on average 36,000 deaths per year

Pandemic Influenza

  • Antigenic Shift: Occurs from genomic mixing of distinct virus strains with human strains.

    • Avian, Swine, etc.

  • New Strain of Influenza:

    • Humans will have no preexisting immunity

  • Efficacy of Antivirals: Unknown

  • No Vaccine will be available

  • Avian Influenza is not yet a Human Pandemic

  • Cannot Predict Level of Virulence

Historical Consequences

Overarching Objectives

  • Phase: Pre-Pandemic

  • Reduce opportunities for human infection

  • Strengthen Early Warning Systems

  • Phase: Emergence of a Pandemic

  • Contain or delay the spread at the source

  • Phase: Pandemic Declared and Spreading

  • Reduce morbidity, mortality, and social disruption

  • Conduct Research to guide Response

SARS: Window to a Pandemic

  • Emerging Respiratory Infection in a Globalized World

    • Travel and Commerce

    • Communication Alerts

  • High Mortality

    • High Secondary Infection Rate in Healthcare Workers

  • No Vaccine

  • Unknown Response to Antivirals

SARS Implementation Strategies :

  • Singapore: Patients with respiratory symptoms seen outside the Emergency Department

  • Toronto: EMS personnel restricted transport of patients with respiratory symptoms.

  • Once case definition present: High Index of Clinical Suspicion among Clinicians

  • Worked in Allentown

SARS Lessons Learned

Developing: Overcrowding

Developed: Travel

Severe acute respiratory syndrome

From Wikipedia, the free encyclopedia

Avian Influenza

Greatest Growth: Asia/Pacific and Latin America

  • Human Resources

  • Overwhelming Patient Load

  • Care for Non-Infectious Patients ie. CVA, MI

  • Surge Capacity: Alternative Care Sites

  • Ethics: Ventilator Triage

Climate Change and Infectious Disease

Climate Change???

  • Thursday, 14 March 2007, 19,577 recorded cases of dengue were reported. The national average incidence rate is 325.8 per 100,000 inhabitants (Source: Mercosur and MSPBS).

  • The dengue outbreak is concentrated in the capital city of Asunción Capital (incidence rate = 1166.6 per 100,000), .

  • Climate in the form of continuous rainfall has played a major role in this outbreak.

Supersize Me!!!

Global Terrorism: Influence of Globalization

  • Internet has become a significant recruitment tool.

  • Enabled people with like minded ideologies to have a virtual relationship.

    • Real threat is not only Al-Qaeda but Al-Qaeda “Inspired” Groups.

  • Terror strategies can be easily shared

    • Example Bomb building

Global Terrorism: Are we preparing for the right threats?

  • Efforts have focused on CBRNE

  • Most likely threat: Suicide Bombing or Improvised Explosive Device

  • Examples London, Madrid, Mumbai, bombings.

  • Recent attempts in Glascow and London underscore this persistent threat.

Globalization and its Impact on Health

  • The world has become increasingly interconnected and interdependent

  • This has positive and negative consequences.

  • Every health system responder should be aware of the new health threats posed by globalization and take a leadership role to educate others in there health system.

Educational Framework for Disaster Medicine and Public Health Preparedness


  • Create an educational framework that would meet the practical needs of all health system responders.

  • Consistency and common lexicon among all learners and level of responders.

  • Create a framework that would allow for scientific evaluation and assessment.


  • Systematic Review (Jan. 2004-July 2007) peer reviewed, and unpublished (ASPR, CDC,DHS)

  • Convened an Expert Panel

  • Identified Commonality and Gaps: Ethics, Law, Mortuary, Risk Communication, Mental Health, Cultural Competence, Leadership.

Learning Matrix

For each competency and responder category, learning objectives must be developed to accommodate persons in the target group who perform at different levels and in varying degrees based on their educational level, experience, professional role, and job function in disaster planning, mitigation, response, and recovery.

For each competency and responder category, learning objectives must be developed to accommodate persons in the target group who perform at different levels and in varying degrees based on their educational level, experience, professional role, and job function in disaster planning, mitigation, response, and recovery.
















Next Steps

  • Development of Learning Objectives

  • Development of Evaluation Measures

  • Prospective Randomized/ Control Educational Trial (web-based vs. didactic).

Bombings: Blast Injury

  • Primary Blast Injury:

    • Overpressure Wave Impacts Hollow Viscous and Air-filled Organs.

    • Examples: TM rupture, Blast Lung, Intestinal perforation Cerebral Contusion???

  • Secondary Blast Injury:

    • Most common type of injury.

    • Due to shrapnel or secondary foreign objects that fly into victim

  • Tertiary Blast Injury:

    • Victim thrown into stationary object

Triage: Sorting patients…sort of.

  • MCI Triage

    • Breakdown into two categories

    • Urgent or Non-Urgent

  • Triage should take place outside ED

  • Insufficient Evidence to support any particular Triage Methodology START vs. MASS vs. Priorities

Injury Severity

  • Open Air Bombing victims usually present at two extremes.

    • Either ISS less 5 or ISS greater than 15

  • ISS greater than 15 considered critical and is associated with increased mortality.

  • Critical Mortality: The number of patients who presented to the hospital with an ISS >15/ Total Number of with ISS of 15.

Critical Mortality Rates: Identifying Preventable Deaths

  • Buenos Aires 29%

  • Beirut 37%

  • NYC 38%

  • London 15%

  • Israel Confined Space 18%

    • Immediate Mortality Confined 46%

    • Open Air 7%

  • Average is usually around 20 %

Critical Mortality and Overtriage

  • Landmark study: Direct Correlation

    • Dr. Eric Frykberg 2002

    • Greater Overtriage the Greater the Critical Mortality

      This is disputed

      London only had a 35% overtriage rate

      New York 70%

      Beirut 80%

      Madrid had 89%

Virginia Tech Case Study: You are a Level 3 Trauma Center

  • April 16th 2007 Campus of Virginia Tech

  • Mass Shooting: Multiple Victims

  • At least 30 Dead (33 found dead at the scene including the shooter).

  • 26 Victims needed to be evaluated

  • Closest Level I Center was 45 miles away.

Unable to Medevac

  • Patients Distributed Equitably

  • Regional Response included 2 Level 3 Trauma Centers and 1 Non-Designated

  • 25 out of the 26 patients triaged in the field

  • START Triage

Triage broke down into two groups

Injury Severity

  • 12/26 patients with ISS> 9

  • 5 patients with ISS> 15

  • Avg. ISS of 8.2

  • Previous Israeli studies have comparatively evaluated gunshot MCI from bombing MCI

  • Gunshot MCI tend to have a moderate ISS score of 9 or greater

  • In previous studies it has been accepted that one can eliminate those DOA

Critical Mortality

  • 1 victim was DOA another victim died after arrival at the hospital.

  • Critical Mortality Rate ???

  • 1/5 = 20%.

  • Trick question you could calculate either way but…

Overtriage??? Not a Friend but is it a Foe?

  • Overtriage calculated

  • Number of Red and Yellow – Total no. ISS > 15/ Total No. Red and Yellow

  • Overtriage was 69%

  • Recent modeling study also demonstrated great variability with overtriage and its relationship to critical mortality.

Lessons Learned:Level I or not be ready!

  • Preventing Copycats?

    • Mental Health screenings for those getting handguns

    • Gun control measures

  • Rural America is not Immune

  • Level I Trauma Centers should take a proactive role in regional education

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