Arming Hospital Ships of the Future: Hybrid Wars Require a Major Change.

INTRODUCTION: It is time to provide heavier defense systems to U.S. Navy hospital ships. They serve vital functions in both the military and emergency management spaces. They provide medical support for combat operations and can also convey the empathy and generosity of the American people when used in humanitarian assistance and disaster relief response. Hospital ships are often key to success in scenarios that require the international deployment of resources and medical expertise. Hospital ships serve a dual purpose and hence are subject to regulations that do not address all wartime mission requirements and necessary defensive capabilities. The current U.S. Navy's interpretation of the Geneva Conventions regarding the visibility, lack of defensive capabilities, and inability to use encrypted communications needlessly endangers medical platforms and personnel in the modern environment. METHODS: The authors (including senior author F.M.B.-a recognized (International Health Law expert) reviewed relevant literature and have evaluated the policies of belligerent parties in past and current conflicts. These increasingly appear to target civilian infrastructure including medical facilities and may increase the risk to hospital ships. This demonstrable current hybrid warfare appears to include purposeful attacks on health care facilities and as such hospital ships should have additional defensive measures. RESULTS: Hybrid warfare and its focus on civilian infrastructure and health care targets are highly visible in the acts of both state and non-state actors and may encourage others to purposefully target health care facilities and personnel. Evidence of this is seen in the current Russian invasion of Ukraine, where since the invasion a year ago 1,218 Ukrainian health facilities have been damaged, including 540 damaged hospitals, 173 of which were totally destroyed and turned into "piles of stones." CONCLUSIONS: In today's conflicted global environment, the clear identification of hospital ships leaving them relatively undefended and denying encrypted communication is the folly of a bygone era. Hospital ships may be targeted because they are brightly lit soft targets that can deliver a large payoff by their destruction. It is time to adapt to the global reality and move on from the tradition of painting hospital ships white, adorning them with red crosses, keeping them unarmed, maintaining open communications, and illuminating them at night. The increasing threats from hybrid warfare and unprincipled adversaries to medical platforms and providers of health care demonstrate that hospital ships must be capable of self-defense. The U.S. Navy is designing new platforms for medical missions and the debate, no matter how uncomfortable, must now occur among major decision-makers to make them more tactical and defensible.

Unleashing the global potential of public health: A framework for future pandemic response.

Public health emergencies, especially pandemics, need to be managed globally, and on several levels, emphasizing the importance of leadership, communication, and synchronization of measures, data, and management plans in contrast to the management of the Coronavirus-19 pandemic, which illustrated diverse strategies employed by various nations. This paper aims to review and discuss whether globalized diseases in a globalized world should be managed by globalized public health. Using a systematic literature search, followed by a non-systematic literature review, selected studies were grouped into topics, and analyzed, using content analysis to enhance the conclusive results. The results present a roadmap towards a re-envisioned framework highlighting key areas of focus: data-driven decision-making, robust technology infrastructure, global cooperation, and ongoing public health education, as part of a coordinated global response. This article reveals the weaknesses of current pandemic management systems and recommends new steps to further strengthen the management of future pandemics.

The implication of a translational triage tool in mass casualty incidents: part three: a multinational study, using validated patient cards.

BACKGROUND: Mass casualty incidents (MCI) pose significant challenges to existing resources, entailing multiagency collaboration. Triage is a critical component in the management of MCIs, but the lack of a universally accepted triage system can hinder collaboration and lead to preventable loss of life. This multinational study uses validated patient cards (cases) based on real MCIs to evaluate the feasibility and effectiveness of a novel Translational Triage Tool (TTT) in primary triage assessment of mass casualty victims. METHODS: Using established triage systems versus TTT, 163 participants (1575 times) triaged five patient cases. The outcomes were statistically compared. RESULTS: TTT demonstrated similar sensitivity to the Sieve primary triage method and higher sensitivity than the START primary triage system. However, the TTT algorithm had a lower specificity compared to Sieve and higher over-triage rates. Nevertheless, the TTT algorithm demonstrated several advantages due to its straightforward design, such as rapid assessment, without the need for additional instrumental interventions, enabling the engagement of non-medical personnel. CONCLUSIONS: The TTT algorithm is a promising and feasible primary triage tool for MCIs. The high number of over-triages potentially impacts resource allocation, but the absence of under-triages eliminates preventable deaths and enables the use of other personal resources. Further research involving larger participant samples, time efficiency assessments, and real-world scenarios is needed to fully assess the TTT algorithm's practicality and effectiveness in diverse multiagency and multinational contexts.

Social and Healthcare Impacts of the Russian-Led Hybrid War in Ukraine - A Conflict With Unique Global Consequences.

Russia's fear of Ukraine becoming a member of the European Union and the North Atlantic Treaty Organization catalyzed the current conflict in Ukraine. The invasion also alarmed other countries, such as Finland and Sweden, who have themselves considered a formal partnership with NATO. Russia's actions to date have created massive instability and political tensions that uniquely influence the health and socio-political life of civilians in Ukraine and the entire region. The direct and indirect threats of war "gone regional," "global", or "nuclear" have energized these countries and their historical alliances to reassess their own socio-political, environmental, and health-care consequences. All countries of the region have clear histories of forced occupation and decades of threats resulting from World War II and its aftermath. The purpose of this rapid communication is 2-fold. First, it discusses the socio-political and health-care consequences of the ongoing Ukrainian conflict in Finland, Russia, Sweden, Poland, and Ukraine. Second, it clarifies the most essential elements of the Hybrid War which cause uniquely distinctive violations of humanitarian laws, treaties, and conventions.

Hybrid warfare and counter-terrorism medicine.

INTRODUCTION: March 9, 2022. An airstrike by Russian forces destroying a maternity hospital in Mariupol, Ukraine. The image of a severely injured pregnant woman covered in blood being stretchered away against the backdrop of destroyed buildings. Mutterings of the use of chemical weapons. This paper is a primer for healthcare personnel and health systems on hybrid warfare and counter-terrorism medicine. DISCUSSION: While recent events and images arising from conflicts around the world represent a cruel hallmark in today's history, attacks against healthcare facilities and innocent civilians are not new and continue to be perpetrated around the world. In war, the Geneva Convention protects civilians and healthcare institutions from harm but when war crimes are being committed and civilians knowingly targeted, parallels from a healthcare perspective can be drawn with terrorism events. Increasingly, civilian institutions and in particular the healthcare sector, are drawn into such conflicts and understanding the health system impact of hybrid warfare and other asymmetrical attack methods is of great importance. CONCLUSION: The field of Counter-Terrorism Medicine (CTM) explores the healthcare impacts of intentional, man-made attacks and much recent research and discussions around this topic are extremely relevant and applicable not just to the ongoing hybrid war in Ukraine, but to today's threat climate all around us.

Russia's Hybrid Warfare in Ukraine Threatens Both Healthcare & Health Protections Provided by International Law.

Hybrid Warfare is on display because of the unjustified Russian invasion of Ukraine. This is characterized by numerous crimes against civilians as seen vividly during the occupation of the town of Bucha where rape, torture, murder, and looting seem to reflect Russian military policy, leadership, and command guidance. Of particular concern is the threat to hospitals and health care as well as vital life support. Numerous hospitals have been damaged and destroyed. Hospitals are not tactical military targets and targeting health care facilities and personnel ignores traditional jus in bello and ignores numerous conventions established to stabilize the global order. The Russian-proclaimed "special operation" in Ukraine has been characterized by barbarian warfare in which the Russian military uses weapons against the civilian population and civilian infrastructure. The aggressors have embarked on a purposeful terror campaign through infrastructure attacks, which are of little military value except to demoralize the nation's people. This is evident with Russian missile and drone attacks on electric, water, and health care in Ukraine. Warfare now and in the future may be increasingly aimed at demoralizing civilian populations and reducing the will of the people and their government to resist. The Ukrainian invasion clearly shows that this use of hybrid warfare should be met with a strong reaction of the international community at the earliest possible stage, especially the supposedly peace-loving neutral countries, or else the future is expanded unlawful and barbaric military conflict.

Narcissistic Sociopathy in Global Autocratic Leaders: Arrested Development, Obsessive Demand for Power, and the Emergence of Unlawful Hybrid Wars.

There are several reasons why war occurs. The most lethal wars are those caused by 1 man's decisions solely driven by an obsessive need for power. With disregard for International Humanitarian Law and the Geneva Convention, these wars, referred to as hybrid warfare, purposefully target civilians directly resulting in millions of deaths, injuries, mass migration, and other severe global and public health consequences. The purpose of this commentary is to investigate the developmental nature of those decision-makers and the consequences of their acts of aggression both locally and globally. There is a clear relationship between the psychological developments of individuals with narcissistic and psychopathological disorders and the implications of an abnormal progression of these individuals and their obsessive desire for singular leadership, which seriously impacts health-care security and its essential elements provided by international humanitarian law and Geneva Convention. Current double standards of the West allow narcissistic sociopaths and autocratic leaders to neglect international law, especially the so-called international humanitarian law. This double standard must be ceased and replaced by an international investigative system with universal standards, a special tribunal covering hybrid war crimes as well as the crime of aggression, and to prevent future leaders from choosing the same strategies.

Developing a translational triage research tool: part two-evaluating the tool through a Delphi study among experts.

BACKGROUND: There are different prehospital triage systems, but no consensus on what constitutes the optimal choice. This heterogeneity constitutes a threat in a mass casualty incident in which triage is used during multiagency collaboration to prioritize casualties according to the injuries' severity. A previous study has confirmed the feasibility of using a Translational Triage Tool consisting of several steps which translate primary prehospital triage systems into one. This study aims to evaluate and verify the proposed algorithm using a panel of experts who in their careers have demonstrated proficiency in triage management through research, experience, education, and practice. METHOD: Several statements were obtained from earlier reports and were presented to the expert panel in two rounds of a Delphi study. RESULTS: There was a consensus in all provided statements, and for the first time, the panel of experts also proposed the manageable number of critical victims per healthcare provider appropriate for proper triage management. CONCLUSION: The feasibility of the proposed algorithm was confirmed by experts with some minor modifications. The utility of the translational triage tool needs to be evaluated using authentic patient cards used in simulation exercises before being used in actual triage scenarios.

The Annual Global Incidence Rate of Extreme Weather Event Disasters Appears Positively Correlated with World GDP, 1961-2020.

OBJECTIVE: This study compared the per capita annual global incidence rate of disasters caused by natural hazards with the annual world real gross domestic product, GDP (per global capita), as reported during 1961 through 2020. METHODS: Sixty (60) values for the world real GDP per global capita (in constant 2015 $USD) were compared to corresponding annual values for global incidence rates for five natural disaster subgroups and then for a total of twelve individual disaster types that comprise the subgroups; each expressed as an annual global incidence rate (in terms of annual incidence per 100,000 persons). Calculations of multiple linear regression, ANOVA, and Pearson's correlation coefficient were performed for comparing population-adjusted values for GDP to corresponding values. RESULTS: Four out of five hydrological and meteorological disasters were found to have a positive correlation with GDP. Results of the analysis revealed a relatively high degree of correlation between world GDP and the annual incidence of flood and storm disasters (P = 6.21 × 10-10 and P = 4.23 × 10-4, respectively). The annual incidence of heat waves and cold weather disasters also appeared to correlate with GDP (P = .002 and P = .019, respectively). In comparison, wet landslides indicated no such correlation (P = .862). No significant associations were found among the seven other individual biological, climatological, and geophysical disasters and GDP. CONCLUSION: The global incidence of four extreme weather (hydrometeorological) disasters appear to be positively associated with world real GDP during 1961-2020. These findings contradict previous postulates that the risk of disaster incidence is inversely associated with the capacity of the population.

An Epidemiological Analysis of Terrorism-Related Attacks in Eastern Europe from 1970 to 2019.

INTRODUCTION: Over the past five decades, Eastern Europe has seen relatively little in terms of terrorist attacks. The recent escalation of the Russo-Ukrainian conflict has, however, placed a new spotlight on the region, and new questions and concerns around war, conflict, insurgency, and terrorism are being posed. The Russian invasion and extensive combat operations, the largest in Europe since World War II, are occurring across Ukraine where there are 15 active nuclear reactors, not including the Chernobyl site, that are vulnerable to attack or sabotage. In addition, Eastern Europe has been heavily affected by COVID-19, exposing broad vulnerabilities in an otherwise fragile health care system. This raises concerns over the ability of Eastern European health care institutions to absorb surge and manage terrorist attacks or acts of violent extremism. This study provides an epidemiological description of all terrorism-related fatalities and injuries in Eastern Europe sustained from 1970 - 2019. METHOD: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database functions for all terrorism events which occurred in Eastern Europe from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of this study. Primary weapon type, country where the incident occurred, and number of deaths and injured were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. RESULTS: There were 3,901 terrorism-related events in Eastern Europe between the years 1970 and 2019, inclusive. In total, the attacks resulted in 5,391 deaths and 9,538 persons injured. Explosives were the most commonly used weapon type in 59.2% of all attacks in the region, followed by firearms in 27.6%. CONCLUSION: From 1970 through 2019, a total of 3,901 terrorist attacks occurred in Eastern Europe, inflicting 5,391 deaths and 9,538 injuries. Of those, 72.3% occurred in Russia and Ukraine. Terrorist attacks sharply declined since the peak in 2014, but there is an overall uptrend in attacks since the 1970s.

The Moral, Ethical, Personal, and Professional Challenges Faced by Physicians during the COVID-19 Pandemic.

The COVID-19 pandemic, apart from the main problems concerning the health and life of patients, sparked a discussion about physicians' moral and social professional attitudes. During a pandemic, physicians have the same ethical, moral, and medical responsibilities, however, the situation is different since they are self-exposed to a danger, which may influence their willingness to work. The problem of the professional moral attitudes of health care workers, recurring in ethical discussions, prompts us to define the limits of the duties of physicians in the event of a pandemic, hence this research aimed to assess these duties from an ethical perspective and to define their boundaries and scope. The study was conducted in May and June 2020 in the city of Lublin, covering all medical centers, and the questionnaire was completed by 549 physicians. The research was conducted in four areas: emergency standby in the event of a disaster, even if it is not requested; willingness to work overtime in the event of a disaster, even without payment; willingness to take health risks by caring for people who are infectious or exposed to hazardous substances; readiness to be transferred to other departments in the event of a disaster. Although most of the respondents declared to be agreed on personal sacrifices in the performance of professional duties, they were not prepared for a high level of personal risk when working in a pandemic. Excessive workload, its overwhelming nature, and personal risk are not conducive to readiness to work overtime, especially without pay. Research shows how important it is to respect the rights and interests of all parties involved in a pandemic. Physicians' duty to care for a patient is also conditioned by the duty to protect themselves and should not be a tool for intimidating and depersonalizing their social and professional lives.

Civilian Population Victimization: A Systematic Review Comparing Humanitarian and Health Outcomes in Conventional and Hybrid Warfare.

OBJECTIVE: The main objective of this study was to summarize the Hybrid War's core characteristics and humanitarian and medical impacts. METHOD: A Systematic Literature Review according to PRISMA guidelines, using the following keywords, 'Hybrid War,' 'Humanitarian Law,' 'Human Rights,' 'Lawfare,' and search engines PubMed, Scopus, Web of Science, and Gothenburg University's database to collect literature from 2000 to 2022 in English was conducted. The eligibility of qualified articles was assessed, an inductive qualitative thematic analysis was applied, and the scientific evidence of each selected piece was evaluated. RESULTS: The objectives of a Hybrid War are to achieve the tactical and strategic goals in a battle rather than to save civilian lives. It involves networks of state and non-state actors with various means of military and militia influences and strategies, creating difficulties in implementing, controlling, and evaluating the International Humanitarian Law's "A State responsibility" principle, to gain insight into an armed conflict. It targets populated civilian areas and raises ethical and moral concerns by using Lawfare. CONCLUSIONS: Hybrid War's multi-domain action should be met with multi-dimensional approaches and a doctrine of 'acceptable losses.' Its characteristics and consequences should be learned and taught. Several measures need to be implemented to counteract its impacts, and a flexible surge capacity should be designed, planned, and executed.