Disparities in disaster healthcare: A review of past disasters.

OBJECTIVE: To review the literature on the effects seen after disaster on those with poor social determinants of health (SDOH) and individual social needs. DESIGN: The Disaster Preparedness and Response Committee of the American College of Emergency Physicians (ACEP) formed a work group to study healthcare disparities seen in disaster. This group was composed of six physicians on the committee, all of whom have extensive background in disaster medicine and the chair of the committee. A systematic literature review regarding past disasters and all the healthcare disparities seen was undertaken with the goal of organizing this information in one broad concise document looking at multiple disasters over history. The group reviewed multiple documents regarding SDOH and individual social needs for a complete understanding of these factors. Then, a topic list of healthcare disparities resulting from these factors was composed. This list was then filled out with subtopics falling under the header topics. Each member of the workgroup took one of these topics of healthcare disparity seen in disasters and completed a literature search. The databases reviewed include PubMed Central, Google Scholar, and Medline. The terms queried were disaster, healthcare disparities, disaster healthcare disparities, healthcare disparities associated with disasters, SDOH and disaster, special populations and disaster effects, and vulnerable populations and disaster effects. Each author chose articles they felt were most representative and demonstrative of the healthcare disparities seen in past disasters. These social determinant factors and individual social needs were then cross referenced in relation to past disasters for both their causes and the effect they had on various populations after disaster. This was presented to the ACEP board as a committee report. RESULTS: All the SDOH and individual social needs showed significant negative effects for the populations when combined with a disaster event. These SDOH cut across age, race, and gender affecting a wide swath of people. Previous disaster planning either did not plan or under planned for these marginalized populations during disaster events. CONCLUSIONS: Disparities in healthcare are a pervasive problem that effects many different groups. Disasters magnify and more fully expose these healthcare disparities. We have explored the healthcare disparities with past disasters. These disparities, although common, can be mitigated. The recognition of these poor determinants of health can lead to better and more comprehensive disaster planning for future disasters. Subsequent research is needed to explore these healthcare disparities exacerbated by disasters and to find methods for their mitigation.

Structural Inequities, HIV Community-Based Organizations, and the End of the HIV Epidemic.

Community-based organizations (CBOs) are integral to achieving the goal of Ending the HIV epidemic (EHE). Their familiarity with and proximity to communities position them to effectively implement strategies necessary to address determinants of health through their formal and informal medical and social services. However, structural inequities have contributed to the demise of many organizations that were instrumental in early responses to the HIV epidemic. We define structural inequities for HIV CBOs as systems in which policies, institutional practices, organizational (mis)representations, and other norms work to produce and maintain inequities that affect CBOs' ability to survive and thrive. In this discussion, we describe the organizational threats to grassroots HIV CBOs and the risks to livelihood and longevity, including examples. The invaluable role of HIV CBOs in EHE and their role in responding to existing and novel infectious diseases like COVID-19 should not be overlooked. Recommendations to promote structural equity are offered. (Am J Public Health. 2022;112(3):417-425. https://doi.org/10.2105/AJPH.2021.306688).

The Lived Experience of Chronic Hepatitis B: A Broader View of Its Impacts and Why We Need a Cure.

Chronic hepatitis B (CHB) is one of the most widespread liver diseases in the world. It is currently incurable and can lead to liver cirrhosis and cancer. The considerable impacts on society caused by CHB through patient mortality, morbidity, and economic loss are well-recognised in the field. This is, however, a narrow view of the harms, given that people living with CHB can be asymptomatic for the majority of their life-long infection. Of less-appreciated importance are the psychosocial harms, which can continue throughout an affected person's lifetime. Here we review the broad range of these impacts, which include fear and anxiety; financial loss and instability; stigma and discrimination; and rejection by society. Importantly, these directly affect patient diagnosis, management, and treatment. Further, we highlight the roles that the research community can play in taking these factors into account and mitigating them. In particular, the development of a cure for hepatitis B virus infection would alleviate many of the psychosocial impacts of CHB. We conclude that there should be a greater recognition of the full impacts associated with CHB to bring meaningful, effective, and deliverable results to the global community living with hepatitis B.

A Platform and Clinical Model to Enable Medicare's Chronic Care Management Program.

In 2015, the Centers for Medicare & Medicaid Services (CMS) implemented a new benefit called chronic care management (CCM). A recent CMS-commissioned study of the program showed that CCM is effective in increasing advance care planning and decreasing overall costs. Despite positive effects on care planning, utilization, and cost, the CCM program remains underutilized. The authors sought to develop a platform to enable scale of the CCM program, and to report outcomes associated with its use. A technology and integrated clinical staff platform was built to enable a scalable, evidence-based implementation of the Medicare CCM program. The model created care management data elements that were used to flag clinical and utilization risks such as falls, mortality, hospitalization and polypharmacy. In 2018, CCM support was provided for 26,500 patients. Logistic regression analyses were used to identify risk factors associated with hospitalization. The cohort experienced 2679 hospitalizations (184 admissions per 1000 patient months per year). Among patients residing in non-nursing home settings, a higher Gagne mortality risk was associated with a 32 times greater chance of being hospitalized. Other positive predictors of hospitalization included being a nursing home resident and being ambulatory without assistance. Negative predictors of hospitalization included being flagged as having a high hospitalization risk, and scoring in the low-risk category for falls or polypharmacy. This CCM model is a scalable method of supporting care management for people with multiple chronic conditions, and can help identify risk factors for hospitalization.

COMPUTATIONAL ASSESSMENT OF PREGNANT WOMAN MODELS EXPOSED TO UNIFORM ELF-MAGNETIC FIELDS: COMPLIANCE WITH THE EUROPEAN CURRENT EXPOSURE REGULATIONS FOR THE GENERAL PUBLIC AND OCCUPATIONAL EXPOSURES AT 50 Hz.

The Recommendation 1999/529/EU and the Directive 2013/35/EU suggest limits for both general public and occupational exposures to extremely low-frequency magnetic fields, but without special limits for pregnant women. This study aimed to assess the compliance of pregnant women to the current regulations, when exposed to uniform MF at 50 Hz (100 µT for EU Recommendation and 1 and 6 mT for EU Directive). For general public, exposure of pregnant women and fetus always resulted in compliance with EU Recommendation. For occupational exposures, (1) Electric fields in pregnant women were in compliance with the Directive, with exposure variations due to fetal posture of <10 %, (2) electric fields in fetuses are lower than the occupational limits, with exposure variations due to fetal posture of >40 % in head tissues, (3) Electric fields in fetal CNS tissues of head are above the ICNIRP 2010 limits for general public at 1 mT (in 7 and 9 months gestational age) and at 6 mT (in all gestational ages).

Application of an induced field sensor for assessment of electromagnetic exposure from compact fluorescent lamps.

The development of scientifically sound instrumentation, methods, and procedures for the electromagnetic exposure assessment of compact fluorescent lamps (CFLs) is investigated. The incident and induced fields from 11 CFLs have been measured in the 10 kHz-1 MHz range, and they are compared with the levels for incandescent and light emitting diode (LED) bulbs. Commercially available equipment was used to measure the incident fields, while a novel sensor was built to assess the induced fields in humans. Incident electric field levels significantly exceed the International Commission on Non-Ionizing Radiation Protection (ICNIRP) reference levels at close distances for some sources, while the induced fields are within the ICNIRP basic restrictions. This demonstrates the importance of assessing the induced fields rather than the incident fields for these sources. Maximum current densities for CFLs are comparable to the limits (in the range of 9% to 56%), demonstrating the need for measurements to establish compliance. For the frequency range investigated, the induced fields were found to be considerably higher for CFLs than for incandescent light bulbs, while the exposure from the two LED bulbs was low. The proposed instrumentation and methods offer several advantages over an existing measurement standard, and the measurement uncertainty is significantly better than the assessment of electric and magnetic fields at close distances.

Telemetry-based field studies for assessment of acute and short-term risk to birds from spray applications of chlorpyrifos.

In a program of avian field studies, radiotelemetry was combined with observations, carcass searches, residue analysis, and determination of brain acetylcholinesterase (AChE) activity to assess the acute and short-term risk posed by chlorpyrifos to birds. Studies were conducted in field crops (brassicas, Poland) and orchards (pome, Italy; citrus, Spain). In total, 25 individual applications of chlorpyrifos were studied on 13 sites. Before each application, birds were fitted with radio transmitters (with minimum stress to birds). Radiotagged birds were monitored and the avifauna observed before, during and for 7 d following each application. A total of 201 birds representing 19 species were radiotagged. In 80% of individual telemetric monitoring periods, birds remained at the study sites. No radiotagged birds showed any sign of intoxication. These included individuals who spent a major proportion of time within treated areas (some individuals located within treated area on >90% of occasions). A total of 7,238 bird sightings were recorded during constant observation during and immediately after application. An additional 4,017 sightings were recorded in 104 individual surveys during 7 d after each application. Two untagged birds (out of 11,255 bird sightings) exhibited atypical behavior for <1 min and 2 to 3 min, respectively, before flying away. This observation (for 0.02% of bird sightings) may or may not have been treatment related. Ten carcasses were recovered (none radiotagged). Residue analysis and brain AChE activity indicated that none was likely to have died from chlorpyrifos exposure. Radiotracking, supported by more traditional assessment methods, was effective for assessing impacts in the field. This extensive field program supports a conclusion that spray applications of chlorpyrifos present a low risk to birds.