International Journal of Academic Medicine

: 2020  |  Volume : 6  |  Issue : 3  |  Page : 163--178

What's new in Academic International Medicine? International health security agenda – Expanded and re-defined

Nicole K Le1, Manish Garg2, Ricardo Izurieta1, Sona M Garg3, Thomas J Papadimos4, Bonnie Arquilla5, Andrew C Miller6, Abbas M Khan6, Tamara Worlton7, Michael S Firstenberg8, Sagar C Galwankar9, Sunil Raina9, Harry L Anderson III10, Rebecca Jeanmonod11, Kristiana Kaufmann12, Donald Jeanmonod11, Annelies De Wulf13, Dianne McCallister14, Christina Bloem5, Ijeoma Nnodim Opara12, Niels D Martin15, Juan A Asensio16, Stanislaw P Stawicki11,  
1 University of South Florida, Tampa, FL, USA
2 New York Presbyterian Weill Cornell Medicine and Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
3 Elitra Health, New York, NY, USA
4 The Ohio State University Medical Center, Columbus, OH, USA
5 SUNY Downstate Medical Center, Brooklyn, NY, USA
6 Nazareth Hospital - Trinity Health Mid-Atlantic, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
7 Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
8 The Medical Center of Aurora, Aurora CO, USA
9 Florida State University, Sarasota, FL, USA
10 St. Joseph Mercy Ann Arbor, Ann Arbor, MI, USA
11 St. Luke's Univeristy Health Network, Bethlehem, PA, USA
12 Wayne State University School of Medicine, Detroit, MI, USA
13 Tulane University School of Medicine, New Orleans, LA, USA
14 Porter Adventist Hospital, Denver, CO, USA
15 University of Pennsylvania School of Medicine, Philadelphia, PA, USA
16 Creighton University School of Medicine, Omaha, NE, USA

Correspondence Address:
Dr. Stanislaw P Stawicki
St. Luke's Univeristy Health Network, Bethlehem, PA

How to cite this article:
Le NK, Garg M, Izurieta R, Garg SM, Papadimos TJ, Arquilla B, Miller AC, Khan AM, Worlton T, Firstenberg MS, Galwankar SC, Raina S, Anderson III HL, Jeanmonod R, Kaufmann K, Jeanmonod D, De Wulf A, McCallister D, Bloem C, Opara IN, Martin ND, Asensio JA, Stawicki SP. What's new in Academic International Medicine? International health security agenda – Expanded and re-defined.Int J Acad Med 2020;6:163-178

How to cite this URL:
Le NK, Garg M, Izurieta R, Garg SM, Papadimos TJ, Arquilla B, Miller AC, Khan AM, Worlton T, Firstenberg MS, Galwankar SC, Raina S, Anderson III HL, Jeanmonod R, Kaufmann K, Jeanmonod D, De Wulf A, McCallister D, Bloem C, Opara IN, Martin ND, Asensio JA, Stawicki SP. What's new in Academic International Medicine? International health security agenda – Expanded and re-defined. Int J Acad Med [serial online] 2020 [cited 2021 Jun 25 ];6:163-178
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Full Text


International health security (IHS) encompasses any natural or anthropogenic occurrence that can threaten the safety of human health and well-being. The American College of Academic International Medicine Consensus Group (ACAIM-CG) developed and recently published a summative assessment highlighting an expanded and re-defined global IHS agenda.[1] The broadened scope of IHS now includes a variety of topics including emerging infectious diseases (EIDs), chronic health conditions (CHCs), social determinants of health (SDH, including access to care), civilian injury and interpersonal violence (CIV), terrorism (inclusive of bioterrorism), planetary changes (volcanic eruptions, earthquakes, wildfires, and climate change), nuclear incidents (both civilian and military), information and cyber-health security (CHS), industrialization and related dangers, globalization, public infrastructure, pharmaceutical production and supply chains, misuse of communication platforms (e.g., social media [SM]), as well as systemic racism and other forms of discrimination. These concerns can directly and indirectly impact IHS both in the short and long term. When considering IHS, our group's primary goal is to emphasize the utility of applying a predefined framework to effectively approach health security threats. This framework comprises a perpetually repeating cycle of prevention, detection, assessment, reporting, response, and addressing needs, with appropriate mitigation efforts built-in and hardwired into the collective health security response. This document provides an outline of the recently published summative assessment in this important area of international academic medicine, as well as our recommendations, regarding appropriate system-wide improvement strategies.


IHS, also referred to as “global health (GH) security” or “public health security,” consists of topics that pertain to well-being of humankind and broadly understood “safety from harm.”[2],[3] Due to the existing overlap between “health” and “security” and the variability in its interpretation, the primary domain can be defined much more broadly when one considers the potential impact of various human-made and nonhuman-made events or factors on “health security” from the GH governance perspective.[4],[5],[6],[7] Within the latter subset, a number of important topics emerge [Table 1].[8],[9],[10] This Executive Summary provides an overview of issues that have the potential to directly or indirectly impact IHS. It was prepared specifically to reflect and highlight the perspective of Academic International Medicine (AIM) as previously defined by the American College of Academic International Medicine (ACAIM).[11]{Table 1}

 International Health Security: the Mechanism for Sustainable Development

As outlined in our summative assessment, the ACAIM-CG advocates for the universal adoption of a continuous IHS assessment cycle [Figure 1]. Such cycle, combined with appropriate mitigation measures hardwired into the overall global IHS response framework, should serve to ensure that ongoing evaluation and process improvement become the prevailing approaches to address the current and future health security crises. Details of the mechanism for sustainable development are provided in our summative assessment document.[1] We will now outline each of the topics listed in [Table 1], providing a foundation for future discourse on the expanded and re-defined construct of IHS.{Figure 1}

Access to care

Within the complex and highly intertwined realm of IHS, it is critical to consider lack of adequate access to healthcare as a significant public health security threat.[12],[13] The current novel coronavirus (COVID-19) pandemic, as well as the 2014–2015 Ebola outbreak, both demonstrate the critical nature of the continued access to care and its role in ensuring health system proficiency across other, closely related domains (e.g., CHCs, SDH, and food security).[14],[15],[16],[17] Furthermore, the importance of access to care to IHS can be readily appreciated when examining the current human migrations and refugee crises.[14],[18],[19],[20] The lack of access to healthcare has been highlighted by the COVID-19 pandemic, but the problem is by no means new and has traditionally been most pronounced in the day-to-day medical disparities like cancer screening and access to advanced therapies. The ACAIM-CG recommends that comprehensive policies be developed at local, regional, national, and international levels to incorporate access to care as an urgent IHS threat.

Biological, chemical, and conventional warfare

War and conflict, especially as it relates to civilian casualties, has been compared to a legalized form of killing.[21] However, the effects of warfare, whether biological, chemical, or conventional in nature, go well beyond the death and physical destruction. More specifically, damage to critical healthcare infrastructure or disruption of pharmaceutical supply chains may result in excess mortality among the affected population(s).[22],[23] In addition, opportunistic infectious diseases may re-emerge during armed conflicts, due to poor sanitary conditions, economic sanctions, or absence of functioning public health infrastructure.[24] Our group believes that the capacity to produce weapons, especially those of biological or chemical type, should be curtailed via global consensus mechanisms.[25] In addition, the introduction of nanotechnology should be closely monitored and regulated in the context of chemical or biological weaponization and delivery platform development.[26] The ACAIM-CG also condemns any armed conflict or military aggression where political or other alternative solution may be feasible, with primary prevention as the cornerstone of our recommended approach.

Chronic health conditions, inclusive of mental health concerns

The increasing prevalence of CHCs, from diabetes to depression, has become an urgent public health issue.[27],[28],[29] This is especially true in the context of access to care in low-and-middle-income regions (LMIRs). The world population ≥60 years of age is expected to triple from 962 million in 2017 to 3.1 billion in the year 2100, and in the context of CHCs, this must be viewed as an IHS threat. Dementia, cardiovascular disease, diabetes, obesity, mental health disorders, human immunodeficiency virus, sexually transmitted diseases, malnutrition, substance abuse, and polypharmacy are among key challenges, with LMIRs affected the most.[30],[31],[32],[33] Strategies aiming to achieve long-term sustainability in the area of CHC management should include focus on innovation, technological advances, and capacity building via global economies of scale.[28],[34] As access to care in many countries is suboptimal, home health and telemedicine are positioned to replace less efficient models.[35],[36],[37] Improved preventative programs for diabetes and cardiovascular screening may be accelerated with point-of-care technology. The aging populations can also benefit from patient-centered care. Finally, early discussions of end-of-life (EOL) care can help reconcile patient and community goals.[38] Home hospice, ethical EOL policy measures, and better community education can significantly improve patient and family experiences.[39]

Civilian injury and interpersonal violence

In addition to the tremendous societal cost of traumatic injury, in general,[40] the impact of civilian injury and interpersional violence (CIV) – ranging from criminal activity to large-scale rioting – on IHS cannot be over-emphasized. The relationship between CIV and IHS is complex, multi-factorial, and confounded by multiple factors and competing priorities. Concerns regarding CIV go well beyond the actual acts of violence, extending into the systemic response to such acts. While a full review of the impact of one on the other exceeds the scope of this work, there are clearly urgent issues that must be acknowledged and considered in the current context.

In response to the COVID-19 pandemic, many communities instituted strict isolation, or “stay at home” orders, with unprecedented travel restrictions and quarantine regulations.[17],[41] The inability of individuals to remove themselves, even if temporarily, from hostile or unsafe living conditions has prompted concerns of increased cases and severity of domestic abuse and other forms of interpersonal violence.[17],[42] In parallel, especially in the United States, the increase in gun violence and mass-shooting events has not only prompted calls for stricter gun control laws but was also paradoxically associated with substantial increases in sales of firearms. Similarly, increased gun sales are seen during the COVID-19 pandemic and have prompted further concerns, regarding the relationships between the increased number of guns and CIV – especially in the context of the complex socioeconomic picture of an evolving pandemic.[42],[43],[44]

During the ongoing COVID-19 pandemic, growing political polarization and worsening socioeconomic inequity led to significant increases in social justice demonstrations and in some cases culminated in episodes of rapidly escalating violence. The occurrence of rioting, looting, and shootings and the systemic response to such events can lead to significant disruptions across over-burdened public services, including the healthcare system. In addition, such events can have a substantial impact on the trust required between the citizenry and healthcare leadership to achieve mutual goals, leading to concerns regarding both the access to care and health outcomes.[17],[45]

Furthermore, there must be a greater recognition and awareness regarding the long-term consequences of social unrest and civilian acts of violence. The costs in terms of lost productivity, direct and indirect healthcare costs (especially in populations with limited access to health insurance), and life-long disability are substantial and likely under-appreciated. In the current era of over-burdened healthcare systems, limited financial resources, and the presence of multiple competing priorities, the impact of CIV on IHS becomes clear.[46],[47],[48] Finally, moving beyond the long-term medical costs of injury-related physical disabilities, we must recognize the tremendous impact of short- and long-term mental health implications due to civilian violence on societal well-being. This includes deep and very much under-appreciated psychological trauma among children who witness or experience various forms of interpersonal violence.[49],[50]

Emerging infectious diseases

The emergence (and re-emergence) of pathogens represents a significant threat to public health, regardless of resource availability.[51],[52],[53],[54],[55] This is clearly demonstrated by the current COVID-19 pandemic.[17] Detection of new IHS threats in this domain is challenging, especially in terms of economic strain and healthcare system capacity.[17],[53],[54],[56],[57],[58],[59],[60] As with other IHS subdomains, EIDs often affect many other areas related to health security, from critical healthcare infrastructure to the economic implications of nonpharmacological interventions, such as social distancing, travel restrictions, or “shelter-in-place” orders.[41]

The ACAIM action plan to prevent the emergence or re-emergence of infectious disease outbreaks includes, but is not limited to, active surveillance for (and timely response to) outbreaks, education and dissemination of key information to all stakeholders, antibiotic stewardship, vector control, and global standardization of management approaches.[54] In a world characterized by continual globalization, ongoing human migrations and increasing ease of travel take on extreme importance to IHS in the context of EIDs.[61],[62] Collectively, the above subcomponents of the expanded IHS framework may contribute to accelerated disease transmission, and when coupled with inadequate response, lack of recognition, and limited awareness of various associated risks, local outbreaks can easily escalate into pandemics.[53],[63],[64],[65]

Food and agricultural security

Broadly speaking, the term “food security” pertains to both the immediate access to food and the ability of existing means of agricultural production and supply chains to ensure sustainable levels of food availability.[65],[66] This subdomain of IHS, much like the other components listed in [Table 1], is deeply embedded within the complex and multi-factorial “health security” matrix. For example, the presence of an EID outbreak, ongoing conflict, or a refugee crisis all affect the fragile balance required to ensure food and agricultural security (FAS) within a region, a country, or at the international level.[67],[68],[69] Moreover, the subdomain of planetary change incorporates a number of threats to agricultural security, including the appearance of invasive species that threaten local food production.[70],[71],[72] Given the critical importance of the issue of FAS, the ACAIM-CG proposes a coordinated global approach, using the proposed IHS action framework [Figure 1] to address this important problem.

Globalization of travel and trade

Modern human activity has had a tremendous impact on both individual and population health and well-being.[73] Key etiological and inherently interrelated concepts include industrialization, globalization of travel and trade, information transfers, and social interactions. Globalization and increased human mobility have greatly augmented the risk of vector-borne disease transmission, especially in the context of planetary climate change (PCC).[74],[75] Moreover, increasing human interconnectedness, while having a positive effect on intercultural relatability and collaboration, has at that same time facilitated the globalization of violence through terrorism, SM, and political destabilization.[76],[77],[78]

Health informatics and cyber-health security

Healthcare institutions are facing increasing CHS threats.[79],[80] Still, the academic healthcare community has been relatively slow to recognize and mitigate concerns related to cyber security.[81] Within this broad area of IHS, three subdomains have been identified: (a) Software supply chain attacks where malignant actors infiltrate the information technology infrastructure via a third-party vendor (e.g., Electronic Health Record add-ons) or partner (e.g., heating, ventilation and air conditioning) systems.[82],[83],[84] Of concern, recent report notes a 200% increase in supply chain attacks across all industry sectors;[84] (b) Internet of things attacks where malignant actors exploit nontraditional devices that are connected to the internet to gain access to sensitive information and critical healthcare/infrastructure systems;[85],[86],[87] and (c) Ransomware attacks where criminals use malicious software to infiltrate computer systems or connected devices in order to encrypt a user's files,[88] often using highly sophisticated and deceptive methods.[89] Once encrypted, the information is indecipherable and inaccessible, requiring a ransom payment to “unlock” it for further access. The ACAIM-CG recommends strict adherence to existing laws, regulations, and standards pertaining to the improvement of CHS.[90] A 2013 U.S. Presidential Executive Order defines, “critical infrastructure” as “systems and assets, whether physical or virtual, so vital…that the incapacity or destruction of such systems and assets would have a debilitating impact on security, national economic security, national public health or safety, or any combination of those matters.”[90] Although further discussion on this important topic is beyond the scope of this Executive Summary, the reader is referred to additional sources for more information.[91],[92],[93],[94],[95],[96],[97],[98]

Industrialization and related topics

Industrial activity increasingly impacts the finely balanced planetary ecological and biophysical system.[99] The World Health Organization (WHO) 2006 Report on the estimate of the environmental contribution to disease mentions that about one quarter of the global disease burden and more than one-third of the burden of disease among children can be attributed to planetary changes. Earth's environmental disequilibrium has been evidenced in the contamination of freshwater bodies, atmospheric pollution, decrease in biodiversity, and other related phenomena.[100],[101],[102] In addition to workplace injury and industrial accidents,[103],[104] industrialization is a key contributor to the contemporary health epidemics of obesity and cardiovascular disease – a long-term trend rooted in the human transition from agricultural to service activities.[105],[106],[107] Industrialization has led to increased energy demands, dependence on fossil fuels, and resultant contribution to global climate change.[108],[109] Additional planetary-level effects include extreme weather events, dangerous and unpredictable heat (and cold) waves, decreased crop yields and nutritional density, as well as emerging new patterns of vector-borne diseases.[53],[110],[111],[112],[113],[114] Extreme weather events lead to greater devastation and property destruction, exacerbating hardships faced by LMIRs, leading to downstream sequelae (e.g., mass hunger, migrations, and armed conflict).[112],[113],[115],[116] Due to the complexity of the topic and its interconnectedness with other IHS domains, the ACAIM-GC recommends a holistic approach to sustainable industrialization and related areas.

Natural disasters

Destructive forces of nature, whether related to atmospheric, tectonic, or volcanic events, have the potential to deeply impact the fragile IHS balance.[115],[117],[118] Volcanic eruptions and associated earthquakes pose significant health security risk and inherently affect human activity and health as more than 500 million people live in proximity to volcanoes.[119],[120] Between 1900 and 2009, nearly 5 million people were affected by volcanic events, with approximately 100,000 deaths caused by ash asphyxiation, thermal injuries from pyroclastic flow, and trauma.[119],[121] Volcanic ash exposure can lead to pulmonary complications (e.g., acute respiratory distress, suffocation, chronic lung disease), ocular injuries/infections, and cutaneous reactions.[122],[123],[124],[125],[126],[127] At higher elevations, ice melting can lead to flooding and mud slides. Moreover, volcanoes can emit harmful gases which include carbon monoxide, sulfur dioxide, hydrogen fluoride, and CO2/H2S (carbon dioxide [CO2], and hydrogen sulfide). These gases accumulate in low areas, may be colorless and odorless, and are easily inhaled leading to a variety of respiratory complaints.[128] Volcanic ash-containing crystalline silica can lead to chronic lung disease. Volcano-associated earthquakes may cause structural damage and displacement.[128] Finally, there may be significant mental health sequelae (e.g., posttraumatic stress disorder [PTSD] and anxiety).[122],[123],[124],[125],[126],[127] Volcanic events may lead to significant socioeconomic disruptions by negatively affecting crops, livestock, water supply, and heavy metal concentrations in the soil, causing a number of direct and indirect effects including property destruction, impaired access to healthcare, and transportation freezes.[128],[129] For example, the largest air transportation halt since the World War II (WWII) occurred during the 2010 Icelandic Eyjafjallajökull eruption, where an estimated 107,000 flights were cancelled during an 8-day period.[130],[131],[132] The event affected nearly half of the global air traffic, including 10.5 million stranded passengers and a staggering cost of over $1.7 billion.[131],[132] Volcanic event readiness requires a comprehensive approach which involves preparation, an emergency action plan, and a postdisaster response framework.[128],[133],[134],[135],[136],[137] Of importance, appropriate mitigation procedures should also be considered in case primary plans/procedures fail. Postdisaster assistance and restoration will require internal and external cooperative efforts, and community involvement is critical. Teaching local community members how to treat/temporize burns, administer inhalers, provide oxygen, and give oral fluids for dehydration can greatly assist local health centers.

Earthquakes can present a significant IHS threat, especially when present in LMIRs, when major damage to healthcare infrastructure is sustained in a relatively geographically isolated setting, or when other exacerbating factors complicate the ensuing relief effort.[117],[138],[139],[140] In the case of the 2010 Haiti earthquake, the confluence of factors from across various IHS subdomains (including poor public health infrastructure and an ensuing cholera outbreak) resulted in a series of events that led to observed mortality and morbidity figures well above those originally projected.[141],[142],[143]

Wind disasters (e.g., hurricanes) represent another important entity in IHS and once again tend to disproportionately affect low-resource areas of the globe.[115],[144] In addition to significant loss of life, major property damage can occur, with healthcare infrastructure being far from immune under such scenarios.[115] Similar to earthquakes, wind disasters have been associated with excess mortality attributable to a confluence of various individual IHS threats co-occurring simultaneously within a short period of time.[145]

Finally, increases in severity and frequency of natural fires have been noted across the globe,[146],[147],[148],[149],[150] including the Amazon rainforest fires in Brazil that prompted great concern among climate scientists.[151] The escalation in Amazon fires may have far-reaching effects on human health and IHS.[1] The major portion (~60%) of the Amazon, covering more than 2 million square miles, is often called “the planet's lungs” and the “carbon sink.”[152],[153] It has been estimated that the Amazon is responsible for processing vast quantities of CO2 and providing about 20% of the world's oxygen.[154],[155] Of importance, about 20% of the rainforest has already been lost, with the tipping point or “danger zone” for human well-being beginning at approximately 25% rainforest lost.[156],[158] While a nontrivial proportion of the Amazon fires may have been set intentionally (e.g., to clear the land for various forms of local economic endeavors), we must remember that this activity only deepens the current climate crisis by destroying CO2 absorbing capacity while actively releasing vast quantities of CO2 into the atmosphere.[157] The current wave of Amazon fires represents the highest number of such events in nearly a decade, with a clear relationship to deforestation activity.[158],[159] In terms of associated health effects, respiratory system exposure to various levels of smoke and volatile chemicals may contribute to both short- and long-term pulmonary sequelae (e.g., acute respiratory infections, chronic obstructive pulmonary disease exacerbations, and bronchial asthma).[160],[161] Emergency visits due to ocular exposures and complaints of eye irritation have also been noted,[161] along with increased incidence of self-reported symptoms, medication use, outpatient and emergency room visits, hospital admissions, and mortality.[162] The strongest associations were observed between forest fire smoke exposure and asthma.[162] Nonpulmonary organ systems (e.g., the kidneys) may also be affected,[112],[163],[164],[165] but this topic is beyond the scope of the current paper. Similar to other areas of IHS, effective solutions to the truly global problem of the crescendo pattern in the reported number of natural fires will require a highly coordinated international response and great degree of commitment from governments around the world.

Nuclear security

Nuclear incidents can be broadly divided into military and civilian occurrences. Although military events (e.g., nuclear war, nuclear terrorism, nuclear weapons testing, and accidents related to handling of nuclear payloads) are of great importance in the overall contexts of potential modulation of planetary change, such scenarios are beyond the scope of the current chapter. For completeness, we are directing the reader to other sources referenced herein.[9],[166],[167],[168],[169],[170] Within the civilian nuclear incident (CNI) subdomain, radioactive exposures can be broadly classified as either medical (e.g., healthcare equipment used for radiation therapy and reagents used in nuclear medicine)[9],[171] or industrial (e.g., power generation, by-products of medical or military production, and long-term storage of nuclear waste).[9],[172] We will briefly discuss each of these, focusing on potential implications on IHS.

Healthcare-related exposures tend to be contained to the immediate environment surrounding the area of radioactive contamination. One CNI of significance took place in Goiania, Brazil.[171] Another incident occurred in Indiana, Pennsylvania.[171] In both cases, injuries and mortalities were limited to a small number of directly affected individuals. Of note, the Goiania incident involved negligent removal and disposal of 50.9 TBq of cesium-137 from a radiotherapy unit.[173] Environmental contamination requires high-intensity cleanup efforts, with acceptable results but some degree of persistent residual radiation exposure risk.[174] Postevent psychological and behavioral effects (termed “radiophobia” and similar to PTSD) were noted among survivors.[175],[176]

In terms of industrial exposures, the most well studied are the nuclear power plant explosion in Chernobyl, Ukraine,[177] and the more recent nuclear reactor meltdowns at the Fukushima Daiichi Nuclear electric plant.[178] Both CNIs exemplify the potential for long-term adverse effects of radioactive isotope releases on the immediate surroundings,[179],[180] as well as the more remote, much subtler downstream exposures, secondary to radioisotope concentration within the food chain.[181],[182],[183] Various studies estimated long-term and long-distance effects of resultant radioactive releases.[183],[184],[185],[186] Similar to medical radiation incidents, both social and mental health consequences have been noted among those exposed.[187],[188] Associations with medical conditions, including malignancies, appear to be less specific and weaker.[189],[190],[191] Appropriately administered food and contamination control programs are effective in minimizing the risk of internal radiation exposure.[183],[192]

Pharmaceutical production and supply chains

In 1982, seven people died in the greater Chicago, Illinois metropolitan area, after consuming acetaminophen that had been intentionally laced with potassium cyanide.[193] While the response by the drug manufacturers has since been recognized as a textbook case in corporate crisis and public relations management, the greater concern was the recognition of how vulnerable pharmaceuticals are to potential tampering and bioterrorism.[194],[195] As a result, the United States Food and Drug Administration (US FDA) and Federal Government – working jointly with pharmaceutical manufacturers – established anti-tampering laws and guidelines to limit the risk of further contamination of the drug supply.[196],[197]

Of concern, such “tampering” events can occur on international scale.[194],[195] This is particularly true when one considers the extensive global supply chain manufacturing process that is involved in the production of consumer pharmaceuticals. Even slight changes in a drug's production – be it the initial formulation, mixing with drug stabilizers, buffers, or binders, all the way to packaging and distribution – can have catastrophic, if not fatal, consequences. The complexity of pharmaceutical development and distribution illustrates that there are numerous opportunities for sabotage, bioterrorism, neglect, or simply human error.[198],[199] Any breakdown, intentional or otherwise, can compromise the safety of medications that millions depend on for health maintenance. Potential observed effects may include avoidance of long-term prescription medications, clinically significant manifestations of fear (e.g., anxiety, post-traumatic stress), as well as economic damage related to combined supply chain disruptions and increased health-care costs.

While there are safeguards built into the entire process to assure quality standards within the pharmaceutical supply chain – including oversight by government agencies, such as the US FDA and European Union European Medicines Agency – the system is not without potential risk(s). Many LMIRs do not have adequate regulatory oversight, established government penalties, and/or adequate public accountability (i.e., public company shareholders) regimes. In addition, for pharmaceuticals that are no longer protected by intellectual property laws, manufacturing may be distributed worldwide, resulting in inconsistent regulatory or quality oversight.[200],[201] In fact, many well-established pharmaceuticals can vary significantly in their drug bio-availabilities and potencies depending on various manufacturing and supply chain factors.[202],[203]

Planetary changes

Our planet is changing and evolving constantly, with continued climate transitions throughout the earth's history becoming the scientifically accepted norm.[204],[205],[206] For the purpose of this discussion, we will refer to this complex set of phenomena simply as “planetary climate change” or PCC. Key areas affected by PCC include agriculture,[207] forestry,[208],[209] species migrations (including the appearance of unopposed invasive species),[210] vector-borne infectious diseases,[211] urban air pollution,[211] wind activity,[115],[212] as well as changes in freshwater availability.[213] Of importance, all of the above elements are closely interrelated, making it difficult to elucidate any binary cause-and-effect relationships, contributing to the highly controversial nature of PCC as a topic. Beyond various direct and indirect effects of PCC on human health,[214] it has been suggested that among the manifestations of the observed human response to PCC are armed conflict and widespread migration.[215],[216]

Perhaps, one of the most impactful current PCC trends is the emergence of increasing temperature variability,[217] which can, in turn, create local weather conditions that regions of the planet may simply not be prepared to handle effectively.[218],[219] One of the proposed models suggests the emergence of “severe and widespread droughts in the next 30–90 years,”[205],[220] with clear implications to other topics discussed in this review, such as food security, EIDs, and human migrations.[221] Another important aspect of PCC management is the need to better understand any effects of solar (and even beyond that, galactic/cosmic) energetic inputs, with special focus on the relationship of such activity on the observed climate behavior patterns.[222],[223] This includes the potential interplay between the earth's magnetic field, solar energetic output, and even the cosmic rays as contributors to the planetary climate conditions, inclusive of the critically important process of cloud formation.[224],[225],[226] Although vast and inadequately understood, the topic of “planetary health” is by default the overarching determinant of human well-being and sustainability.

Public infrastructure and health system resources

Throughout this manuscript, it is evident that adequate public infrastructure and services (PIS) (e.g., transportation, water, power/energy, telecommunications, recreational, and health domains) are of critical importance to health security.[12],[227] PIS are often funded through taxation whereby a portion of gross domestic product (GDP) is invested in the maintenance of infrastructure for the health and welfare of the population.[228] The percentage of GDP spent on PIS correlates with higher overall national GDP, making LMIRs more vulnerable in terms of health security. Most aspects of PIS either directly or indirectly pertain to public health or healthcare delivery, inclusive of complex support mechanisms and structures (e.g., charitable or nongovernmental activity, public–private partnerships, and government spending). There are several models of global public–private ventures which can be broadly grouped into product-, development-, and systems-focused partnerships.[229]

Although the discussion of various possible failure modes in the context of PIS is beyond the scope of this article, it is important to note that deteriorating public infrastructure has been tied to the emergence of epidemiologic risk zones.[230] It follows that regular assessment of PIS is required in ensuring public health preparedness, identifying areas of opportunity, and mitigating any potential threats [Figure 1].[231] The complexity of this topic, and its many interfaces with multiple other IHS domains, stems from the fact that recent technological advances made public infrastructure and health system resources uniquely vulnerable to a broad range of cyber-attacks (discussed elsewhere in this paper); natural disasters (e.g., earthquakes, natural fires, and wind disasters); and various other extrinsic influences (e.g., SM, political forces, and armed conflict).[232],[233],[234],[235]

Social determinants of health

An important component of IHS is the development and continued focus on SDH. This “umbrella” term encompasses the economic and societal conditions that affect an individual's health, highlighting the interconnectedness of global development and IHS. Although there are no strictly defined SDH subdomains, some commonly accepted parameters include access to healthcare, education, employment, socioeconomic status, and safe physical environments (e.g., neighborhood assistance, formal and informal social support networks).[236] These factors are the outcome of public policy and not traditionally considered under the auspices of healthcare but are increasingly recognized as important factors in a society's well-being.

The WHO Commission on Social Determinants of Health (CSDH, 2005–2008) recommended a multi-faceted approach to address inequity in SDH which included housing options, employment options, educational opportunities, universal healthcare, gender equality, fiscal responsibility and opportunity, various social programs, as well as “monitoring, assessment, and evaluation” of intervention effectiveness.[237] In 2011, 125 member states signed the Rio Political Declaration on SDH and this was subsequently adopted as World Health Assembly Resolution 65.8 in 2012. This pledge by member states focuses on equitable policy toward development and health-care, SDH-centric policy-making, and global collaboration and accountability for SDH policy.[238]

SDH implementation is a dynamic process. The inclusion of gender identity as an SDH highlights the importance of continued vigilance to identify and address health inequities.[239] The interlinked nature of these factors makes it evident that SDH and health security can be impacted by nearly every aspect of policy and is not limited by national borders. Such is the case of climate change and its impact on health, including air quality, food security, agriculture, employment, and housing options. With LMIRs disproportionally affected due to insufficient resources, the optimization of SDH for best health outcomes becomes increasingly challenging, from supply chain interruptions to healthcare infrastructure damage.[115],[240] Recognizing the need for continued advocacy, the WHO created a Department of SDH for the 13th General Programme of Work (2019–2023). The final recommendation from the CSDH was for assessment, monitoring, and evaluation of interventions. This is generally consistent with the ACAIM-CG proposed framework [Figure 1]. Work is ongoing to determine the feasibility and accuracy of monitoring for some SDH indicators; however, future national and international programs should consider building intrinsic assessment capacity.[241]

Social media platforms: Dangers of misinformation and misuse

The role of SM platforms in IHS is substantial and is likely to continue to grow.[242] There are certainly many positive aspects of SM, such as the ability to quickly conduct population-level education, surveillance, and even preventive interventions.[242] At the same, there is the “dark side” potential of subverting these powerful platforms to both passively and actively plant misinformation and cause harm.[8] Among the most challenging aspects of SM use in public health and IHS is the need for real-time verification and interception of potentially harmful messaging while at the same time promoting helpful content.[8],[243] The role of SM as a potential agent for the dissemination of harmful medical misinformation is generally under-appreciated. Yet, this emerging IHS threat is not only global but also represents a more pervasive form of harm, where incorrect, erroneous, or outright dangerous information becomes “entrenched” as “accepted truth” or “truthism.”[244] When disseminated widely, through a combination of “likes” and “upvotes,” the factually incorrect or even harmful information may eventually reach the status of “accepted reality” where people tend to believe in the validity of the damaging claim without critically evaluating its merits. In addition to potential harm and elevated risk to individuals, misuse of SM platforms can lead to population-level manifestations through SM “weaponization,” resulting in manipulated public anger and civil unrest.[245] Finally, the unethical opportunism of false promises and exploitation of the naïve can be highlighted by the emergence of unsubstantiated and harmful claims of “disease-modifying behaviors” that may actually lead to significant morbidity and/or mortality,[246],[247] regardless of original intent. One such example is the public health harm created by the anti-vaccination movement, which was greatly aided by the misinformed adoption of SM platforms as “trusted sources.”[8] Due to the truly global reach of SM platforms, the ACAIM-CG urges international cooperation at the governmental level to help curb SM abuse and the propagation of harmful medical misinformation.

Systemic racism and other forms of discrimination

The current COVID-19 pandemic exposed both the severity and the deleterious impact of systemic and structural racism on health outcomes.[17],[248] It has become clear that the observed differences in clinical outcomes cannot be simply explained by expected population differences, pointing to the long-term, deeply embedded effects of systematized inequity across various SDH.[249],[250] The solution to this important problem is as complex as the problem itself and will require a long-term, deliberate society-wide effort.[251] This will involve both integrated and coordinated action across multiple societal sectors, such as healthcare, education, housing, criminal justice/law enforcement, and economics. Self-reflective and intentional systemic transformation of laws, policies, processes, protocols, and practices will be required to create a more equitable present and future. Diversity and inclusion in the work-place, more reflective of society, is a common starting point.

Medicine and the health sciences are well positioned to lead the transformation toward a truly diverse, inclusive, and unbiased environment within which we conduct research, engage in medical education throughout the educational pipeline, advocate for others, and practice clinically. In addition to systemic racism, other forms of systemic discrimination (e.g., gender, sexual orientation, religion, and ethnic/national origin) also require urgent attention. This includes the need to address critical issues related to the other domains of the current IHS agenda, such as access to care, treatment of CHCs, refugee health, SDH, and many other closely intertwined areas. Despite being highlighted by the Sustainable Development Goals, gender inequality continues to be an important cause of health challenges and disparity. Gender discrimination disproportionately impacts women's health through differences in risk exposure, health behaviors, access to care, biased health systems and health research (including data collection), as well as institutional structures and systems. Continued efforts and attention need to be paid to addressing and mitigating health disparities for women. This complex and heterogeneous topic is beyond the scope of the current Executive Summary, but it is hoped that its inclusion in a formal ACAIM-GC statement will compel other academic groups and health authorities to recognize its great importance.

Terrorism, bioterrorism, and related topics

In 2016, there were more than 13,000 terrorist attacks around the world, resulting in over 34,000 deaths.[252] The IHS Expert Community has never faced the current complexity and array of conventional, biological and chemical agents that can cause death, morbidity, disability, social disruption, and economic loss.[253],[254] Humans have engaged in biological and chemical warfare for centuries, with many deplorable acts recorded throughout history.[255],[256],[257] Beyond biological warfare, the use of chemical agents to hurt other humans goes back over 10,000 years, from application of poison to spear tips, to the poisoning of Athenian wells by Sparta, the use of battlefield chemical weapons in the WWI, and the Nazi development of the most lethal nerve agents.[258],[259],[260],[261],[262],[263],[264],[265],[266],[267],[268]

The Centers for Disease Control and Prevention (CDC) defines biological terrorism, or bioterrorism, as the use of biological agents (microbes, toxins, and viruses) as weapons to further personal, religious, or political agendas.[269],[270] Acts of bioterrorism range from a single exposure directed at an individual by another individual or group, to wider scale warfare resulting in mass casualties. This definition may also be extended to include the infliction of harm that involves animals and plants/crops (a.k.a., econo-bioterrorism).[271],[272],[273],[274],[275] Bioterrorism is often considered jointly with chemical terrorism, which is the release of nerve agents (organophosphorus compounds – e.g., sarin gas); vesicants which damage skin and mucous membranes (mustard gas and Lewisite); agents affecting the airway and lungs (i.e., choking agents, phosgene gas); and/or cyanide agents affecting cellular respiration (e.g., hydrogen cyanide and cyanogen chloride).[276],[277],[278] Today's risk of bioterrorism is high because of a normative erosion of the social anathema regarding the use of biological and chemical weapons.[279] In addition, the rise of affordable small-scale science and technology capacity linked with the emergence of asymmetrical warfare (i.e., the interplay between smaller international actors versus traditional monolithic nation states) is a serious threat to populations and resources.[280],[281]

The ACAIM-CG echoes recommendations by the CDC in this domain, with five separate focus areas, each encompassing pertinent training and research: (a) preparedness and prevention; (b) detection and surveillance; (c) diagnosis and characterization of biological and chemical agents; (d) response; and (e) communication.[282] In addition, we advocate strongly for the incorporation of mitigation efforts to optimize the effectiveness of the above-outlined incident response paradigm. To successfully address IHS threats, national and international institutions must provide measures aimed at augmenting public health diagnostics, including microbial recognition and typing, surveillance, enhanced pharmacological therapeutics (e.g., antimicrobials that can overcome resistance), vaccines, chemical sniffers, training, and education.[271] Where applicable, fast-tracking of innovations through various governmental and nongovernmental organizations may help accelerate the work and delivery of new therapies and biological agent-specific remedies (e.g., vaccines, antidotes) to the field. Furthermore, implementation of clinical and field trials during a public health emergency while at the same time respecting cultural differences between societies should be considered. Ensuring the provision of an ethical and just framework for such actions can accelerate the delivery of new therapies to mitigate the potential devastation of biological and chemical terrorism.[63],[283]


IHS is a complex and highly heterogeneous area of expertise. In this document, the ACAIM-CG presented an Executive Summary of key issues that can impact IHS, including EIDs, CHCs, CIV, planetary changes (volcanic eruptions, earthquakes, wildfires, and climate change), nuclear incidents, CHS, industrialization, globalization, pharmaceutical production, misuse of communication platforms (social media), public health infrastructure, SDH, systemic racism (and other forms of discrimination), terrorism (including bioterrorism), and various forms of warfare. These subdomains can directly and indirectly impact IHS both in the short and long term. When considering IHS, we aim to emphasize the utility of applying a predefined framework to effectively approach health security threats. This framework comprises prevention, detection, assessment, reporting, response, addressing needs, and the repetition of this continuous re-assessment cycle. Appropriate mitigation measures should be built into such system. It is hoped that this collective work will provide a foundation for further research within the redefined, expanded scope of IHS.


Dr. Tamara Worlton: The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DoD), the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

Other Co-Authors: This manuscript represents individual contributions and opinions of each ACAIM Consensus Group member. These contributions and opinions do not imply endorsement by the Consensus Group members' institutions.


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