Publications

Epidemic readiness and response command the disproportionate attention of health security decision makers, planners, and practitioners, overshadowing recovery. How patients and their families, health organizations, community sectors, and entire societies recuperate from major outbreaks requires more systematic study and better translation into policy and guidance. To help remedy this neglected aspect of health emergency management, we offer a working definition for epidemic recovery and a preliminary model of postepidemic recovery. Guiding this framework’s development are insights gleaned from the more mature study of postdisaster reconstruction and rehabilitation as well as recognition that postoutbreak recovery—which involves infectious disease, a biological hazard—presents challenges and opportunities distinct from events involving geological or meteorological hazards. Future work includes developing a consensus around characteristics of successful epidemic recovery, applying these metrics to support preincident planning for postepidemic recovery, and using such a scheme to track and inform actual recovery from an epidemic.

As the COVID-19 pandemic continues to progress, most jurisdictions have implemented physical distancing measures to reduce further transmission, which have contributed to reductions in numbers of new cases. As chains of transmission begin to decline, along with new COVID-19 cases, there will need to be decisions at the state level about how to transition out of strict physical distancing measures and into a phased reopening

Stark gaps exist between projected health needs in a pandemic situation and the current capacity of health care and medical countermeasure systems. Existing pandemic ethics discussions have advocated to engage the public in scarcity dilemmas and attend the local contexts and cultural perspectives that shape responses to a global health threat. This public engagement study thus considers the role of community and culture in the ethical apportionment of scarce health resources, specifically ventilators, during an influenza pandemic. It builds upon a previous exploration of the values and preferences of Maryland residents regarding how a finite supply of mechanical ventilators ought to be allocated during a severe global outbreak of influenza. An important finding of this earlier research was that local history and place within the state engendered different ways of thinking about scarcity.

Effective communication about medical countermeasures—including drugs, devices and biologics—is often critical in emergency situations. Such communication, however, does not just happen. It must be planned and prepared for. One mechanism to develop communication strategies is through the use of prospective scenarios, which allow readers the opportunity to rehearse responses while also weighing the implications of their actions. This article describes the development of such a scenario: The SPARS Pandemic 2025-2028. Steps in this process included deciding on a timeframe, identifying likely critical uncertainties, and then using this framework to construct a storyline covering both the response and recovery phases of a fictional emergency event. Lessons learned from the scenario development and how the scenario can be used to improve communication are also discussed.

Aerial spraying of products to kill larvae or adult mosquitoes is a public health measure used to control vector-borne diseases. In some outbreaks, the intervention has evoked controversy and community resistance. This study evaluated how local opinion leaders in US localities affected by Zika think about community engagement in public health policies for outbreak response. In December 2017 through March 2018, 4 focus groups were convened in Houston, TX, New Orleans, LA, Miami, FL, and Brooklyn, NY. They discussed a hypothetical scenario that featured vector control by aerial spraying. Participants (N = 20) more readily accepted this vector control method under 4 conditions: They were informed of alternatives, benefits, and risks for human health and the environment. Public health claims were backed by objective evidence and an authority figure genuinely working in the community’s interests. They received timely notice about how to mitigate toxin exposure. And, aerial spraying helped to protect vulnerable individuals. The community engagement requirements of the local opinion leaders resonate with core principles of recent public health ethics frameworks: namely, personal autonomy, transparency, reasonableness, and solidarity. Participants foresaw problems with community consent in an era of growing social media use and mistrust in governmental and scientific authority. They also debated whether health authorities should use moral-based arguments, in addition to science-based ones, to communicate aerial spraying’s risks and benefits.

The “community resilience” ideal breaks with earlier status quo thinking that it is enough for society to respond to disasters as they occur. Mounting human and economic losses and a several-decades-long upward trajectory in the extreme events (i.e., tropical storms, flooding, drought, and wildfire) occurring each year have made such a reactionary position no longer tenable. Policymakers, practitioners, and populations now aspire more fully for communities to anticipate, withstand, recover from, and emerge even stronger after a disaster.1

Measurement is a community endeavor that can enhance the ability to anticipate, withstand, and recover from a disaster, as well as foster learning and adaptation. This project’s purpose was to develop a self-assessment toolkit—manifesting a bottom-up, participatory approach—that enables people to envision community resilience as a concrete, desirable, and obtainable goal; organize a cross-sector effort to evaluate and enhance factors that influence resilience; and spur adoption of interventions that, in a disaster, would lessen impacts, preserve community functioning, and prompt a more rapid recovery. In 2016–2018, we engaged in a process of literature review, instrument development, stakeholder engagement, and local field-testing, to produce a self-assessment toolkit (or “rubric”) built on the Composite of Post-Event Well-being (COPEWELL) model that predicts post-disaster community functioning and resilience. Co-developing the rubric with community-based users, we generated self-assessment instruments and process guides that localities can more readily absorb and adapt. Applied in three field tests, the Social Capital and Cohesion materials equip users to assess this domain at different geo-scales. Chronicling the rubric’s implementation, this account sheds further light on tensions between community resilience assessment research and practice, and potential reasons why few of the many current measurement systems have been applied

In 2017-18, the Johns Hopkins Center for Health Security conducted a multiphase research project to help inform the development of a strategic approach for communicating about global catastrophic biological risks (GCBRs). In brief, we define a GCBR as a biological development that could adversely affect the human species as a whole or radically change the course of human civilization—for instance, a severe pandemic involving a naturally occurring or deliberately engineered pathogen. GCBRs are an emerging concern among a discrete set of scientists and organizations located principally in Europe and the United States. To conceive and implement activities necessary to prevent or respond to biological threats of a global scale will require effective communication of the issue’s importance—internationally—to a range of people with knowledge, influence, and control of resources.

The authors describe a critical care disaster resource allocation framework developed following a state-wide community engagement process in Maryland. It is intended to assist hospitals and public health agencies in their independent and coordinated response to an officially declared catastrophic health emergency in which demand for mechanical ventilators exceeds the capabilities of all surge response efforts and in which there has been an executive order to implement scarce resource allocation procedures. The framework, built on a basic scoring system with modifications for specific considerations, also creates an opportunity for the legal community to review existing laws and liability protections in light of a specific disaster response process.

The experiences of communities that responded to confirmed cases of Ebola virus disease in the United States provide a rare opportunity for collective learning to improve resilience to future high-consequence infectious disease events.

National investments to facilitate prompt access to safe and effective medical countermeasures (MCMs) (ie, products used to diagnose, prevent, protect from, or treat conditions associated with chemical, biological, radiological, or nuclear threats, or emerging infectious diseases) have little merit if people are not willing to take a recommended MCM during an emergency or inadvertently misuse or miss out on a recommended MCM during an emergency. Informed by the Expert Working Group on MCM Emergency Communication, the Johns Hopkins Center for Health Security developed recommendations for achieving desired public health outcomes through improved MCM communication based on a review of model practices in risk communication, crisis communication, and public warnings; detailed analysis of recent health crises involving MCMs; and development of a scenario depicting future MCM communication dilemmas. The public’s topics of concern, emotional requirements, capacity for processing information, and health needs will evolve as an emergency unfolds, from a pre-event period of routine conditions, to a crisis state, to a post-event period of reflection. Thus, MCM communication by public health authorities requires a phased approach that spans from building up a reputation as a trusted steward of MCMs between crises to developing recovery-focused messages about applying newly acquired data about MCM safety, efficacy, and accessibility to improve future situations.

Community engagement (CE)—involving citizens and civil society in the formulation, implementation, and assessment of policies and programs affecting their well-being – is a centerpiece of US health and security doctrine and growing feature of local problem solving. In disaster and epidemic management, CE is tied to the move from a government-centric to whole-of-community model and shift from readiness and response to resilience aims. Government cannot mount an effective response singlehandedly given finite resources, rigid structures, and limited local knowledge. By encouraging citizen and civil society input, authorities also foster social connectedness, cross-sector collaboration, and collective problem solving which together enhance disaster resilience.

The domestic response to the West Africa Ebola virus disease (EVD) epidemic from 2014-2016 provides a unique opportunity to distill lessons learned about health sector planning and operations from those individuals directly involved. This research project aimed to identify and integrate these lessons into an actionable checklist that can improve health sector resilience to future high-consequence infectious disease (HCID) events.

Local health departments (LHDs) help rally communitywide efforts to manage disasters with health impacts. This responsibility emerged as a centerpiece of the nation’s response to the 2001 terror attacks, including federal public health emergency preparedness (PHEP) grants to local and state health agencies. Encouraged PHEP capabilities include risk communication, building coalitions that integrate businesses and community- and faith-based organizations (CFBOs), opening emergency planning to public input, and mobilizing volunteers. National standards for local public health preparedness also feature community preparedness, including multisector partnerships, vulnerable population initiatives, and 2-way exchanges (eg, town hall meetings, public strategy sessions).

The following narrative comprises a futuristic scenario that illustrates communication dilemmas concerning medical countermeasures (MCMs) that could plausibly emerge in the not-so-distant future. Its purpose is to prompt users, both individually and in discussion with others, to imagine the dynamic and oftentimes conflicted circumstances in which communication around emergency MCM development, distribution, and uptake takes place. While engaged with a rigorous simulated health emergency, scenario readers have the opportunity to mentally “rehearse” responses while also weighing the implications of their actions. At the same time, readers have a chance to consider what potential measures implemented in today’s environment might avert comparable communication dilemmas or classes of dilemmas in the future.

Although the healthcare system is undoubtedly better prepared for disasters than it was before the events of 9/11, it is not well prepared for a large-scale or catastrophic disaster. Just as important, other segments of society that support or interact with the healthcare system and that are needed for creating disaster-resilient communities are not sufficiently prepared for disasters. This report is the culmination of a 2-year project funded by the Robert Wood Johnson Foundation to examine US disaster healthcare with the purpose of identifying changes, innovations, and new efforts that could strengthen the country’s ability to provide medical care in major disasters. In the report, Johns Hopkins Center for Health Security researchers analyze a range of disasters that could confront the United States and consider their impacts on the healthcare system, including how medical care would be delivered in those scenarios, both to victims of the disaster and everyone else. We found that many of the current programs are quite valuable and should continue to be supported, and that several new initiatives should be pursued that would improve the disaster readiness and resilience of the US health sector.

The Johns Hopkins Center for Health Security is working to analyze and deepen scientific dialogue regarding potential global catastrophic biological risks (GCBRs), in a continuation of its mission to reduce the consequences of epidemics and disasters. Because GCBRs constitute an emerging policy concern and area of practice, we have developed a framework to guide our work. We invited experts from a variety of disciplines to engage with our underlying concepts and assumptions to refine collective thinking on GCBRs and thus advance protections against them.

This is a checklist of actions for healthcare, public health, nongovernmental organizations, and private entities to use to strengthen the resilience of their community's health sector to disasters. It is informed by the experience of Hurricane Sandy in New York and New Jersey and analyzed in the context of findings from other recent natural disasters in the United States. The health sector is defined very broadly, including—in addition to hospitals, emergency medical services (EMS), and public health agencies—healthcare providers, outpatient clinics, long-term care facilities, home health providers, behavioral health providers, and correctional health services. It also includes community-based organizations that support these entities and represent patients. We define health sector resilience very broadly, including all factors that preserve public health and healthcare delivery under extreme stress and contribute to the rapid restoration of normal or improved health sector functioning after a disaster. We present the key findings organized into 8 themes. We then describe a conceptual map of health sector resilience that ties these themes together. Lastly, we provide a series of recommended actions for improving health sector resilience at the local level. The recommended actions emphasize those items that individuals who experienced Hurricane Sandy deemed to be most important. The recommendations are presented as a checklist that can be used by a variety of interested parties who have some role to play in disaster preparedness, response, and recovery in their own communities. Following a general checklist are supplemental checklists that apply to specific parts of the larger health sector.

Beginning in 2017, new federal leadership can take important steps to vitalize the role of private citizens and businesses as well as faith-based and community-based organizations in the larger public health emergency preparedness (PHEP) enterprise. A broad consensus exists that government on its own cannot effectively and equitably manage epidemics and disasters. Past events repeatedly demonstrate that actions by citizens and civic groups have helped to curtail the impacts of extreme events and to prompt a more complete recovery from mass trauma. Nonetheless, the full potential of nongovernment forces in disaster readiness, response, and recovery has yet to be realized. Community engagement can enhance the quality of emergency planning, improve protections for vulnerable populations, multiply preparedness and response assets, and, ultimately, save more lives. The incoming administration in concert with Congress has an immense opportunity to enhance the country's resilience to catastrophic health events by steadily investing in robust partnerships between local public health authorities and the communities they serve.

How the US Food and Drug Administration (FDA) and other US government officials convey information about medical countermeasures (MCMs) will affect uptake, compliance, and ultimately survival in the aftermath of a natural disease emergency or a chemical, biological, radiological, or nuclear (CBRN) attack. Moreover, effective communication regarding MCMs has the potential to strengthen psychological resilience as well as engender public trust in science, government, and public health.