**5. Social determinants of health**

An important component of IHS is the development and continued focus on social determinants of health (SDH). This broad umbrella term encompasses the economic and societal conditions that affect an individual's health and underlines the interconnectedness of development and health. Although there is no predefined set of SDH parameters, commonly accepted components include: access to health-care, education, employment, socioeconomic status, and safe physical environment—for example, neighborhood and social support networks [70]. 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 (CDSH) recommended a multifaceted approach to address inequity in SDH, which included housing options; employment options; educational opportunities; universal healthcare; gender equality; fiscal responsibility and opportunity; and social programs as well as monitoring, assessment, and evaluation of interventions for effectiveness [71]. In 2011, 125 member states signed the Rio Political Declaration on Social Determinants of Health and this was subsequently adopted as World Health Assembly resolution 65.8 in 2012. The document focuses on equitable policy toward development and healthcare, SDH-focused policy-making, and global collaboration and accountability for SDH policy [72].

Social determinants of health do not constitute a fixed idea and should therefore be considered a dynamic and evolving concept (and process). The inclusion of gender identity among SDH highlights the importance of continued vigilance to identify and address health inequities [73]. The interlinked nature of these factors makes it clearly evident that SDH and health security can be impacted by nearly every aspect of policy and is not limited by national borders. Let us consider the case of climate change and its impact on numerous health determinants, including employment, air quality, food security, invasive species, agriculture, and housing options. Within this broader context, LMIRs will be disproportionally affected and without sufficient resources, the optimization of SDH for best health outcomes across potentially affected populations becomes increasingly difficult. The unpredictable nature of change may manifest in numerous ways, from supply chain interruptions to health-care infrastructure damage [74, 75]. Recognizing the need for continued advocacy, the WHO created a Department of Social Determinants of Health to lead the SDH effort for the WHO 13th General Programme of Work 2019–2023.

The final recommendation from the CSDH was for assessment, monitoring, and evaluation of interventions. There has been some work to determine feasibility and accuracy of monitoring for specific SDH indicators; however, future national and international programs should consider building intrinsic capability of SDH assessment [76].

#### **6. Biological and chemical terrorism**

In 2016, there were more than 13,000 terrorist attacks around the world resulting in over 34,000 deaths [77]. The IHS expert community has never faced this level of complexity and such diverse array of biological and chemical agents that can cause death, morbidity, disability, social disruption, and economic loss [78, 79]. Humans have engaged in biological and chemical warfare for centuries, with some of the historical applications including deliberate use of manure, plague victims,

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*International Health Security: A Summative Assessment by ACAIM Consensus Group*

Nazi development of the most lethal nerve agents [83–93].

hydrogen cyanide and cyanic chloride) [101–103].

**7. Health security in the context of natural disasters**

populations and resources [105, 106].

and dead animals; the delivery of smallpox-infected blankets to Native American tribes; poisoning of wells with shigella and cholera; and the dispersing of plagueinfested fleas by the Japanese in Manchuria during World War II [80–82]. 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 World War I, and the

The Centers for Disease Control and Prevention (CDC) have defined biological terrorism, or bioterrorism, as the use of biological agents (microbes, toxins, viruses) as weapons to further personal, religious, or political agendas [94, 95]. Acts of bioterrorism range from a single exposure directed at an individual by another individual, to wider scale biological 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) [96–100]. 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 (i.e., 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.,

Today's risk of biological or chemical terrorism is high because of a normative erosion of the social anathema regarding the use of biological and chemical weapons [104]. Specifically, such erosion has occurred because of the modern-day contempt for the 1925 Geneva Protocol, the 1972 Biological Weapons Convention, and the 1993 Chemical Weapons Convention, which collectively outlaw "the development, production, stockpiling, acquisition, and use of chemical and biological weapons [104]." Additionally, 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

Specific recommendations by the CDC include five focus areas, with each area 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 [107]. In addition, the authors of this report advocate strongly for the incorporation of mitigation efforts as critical to optimizing 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 [96]. Where applicable, fast-tracking of innovations through various governmental and nongovernmental organizations (NGOs) will accelerate the work and delivery of new therapies and biological agent-specific vaccines to the field. Furthermore, implementation of clinical and field trials during a public health emergency (PHE) 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 work and delivery of new therapies and vaccines to remedy the potential devastation of biological and chemical terrorism [40, 108].

The planet Earth is our home within the indifferent emptiness of the known universe. Always changing and evolving, the Earth is not a static environment. And

#### *DOI: http://dx.doi.org/10.5772/intechopen.93214 International Health Security: A Summative Assessment by ACAIM Consensus Group*

and dead animals; the delivery of smallpox-infected blankets to Native American tribes; poisoning of wells with shigella and cholera; and the dispersing of plagueinfested fleas by the Japanese in Manchuria during World War II [80–82]. 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 World War I, and the Nazi development of the most lethal nerve agents [83–93].

The Centers for Disease Control and Prevention (CDC) have defined biological terrorism, or bioterrorism, as the use of biological agents (microbes, toxins, viruses) as weapons to further personal, religious, or political agendas [94, 95]. Acts of bioterrorism range from a single exposure directed at an individual by another individual, to wider scale biological 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) [96–100]. 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 (i.e., 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 cyanic chloride) [101–103].

Today's risk of biological or chemical terrorism is high because of a normative erosion of the social anathema regarding the use of biological and chemical weapons [104]. Specifically, such erosion has occurred because of the modern-day contempt for the 1925 Geneva Protocol, the 1972 Biological Weapons Convention, and the 1993 Chemical Weapons Convention, which collectively outlaw "the development, production, stockpiling, acquisition, and use of chemical and biological weapons [104]." Additionally, 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 [105, 106].

Specific recommendations by the CDC include five focus areas, with each area 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 [107]. In addition, the authors of this report advocate strongly for the incorporation of mitigation efforts as critical to optimizing 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 [96]. Where applicable, fast-tracking of innovations through various governmental and nongovernmental organizations (NGOs) will accelerate the work and delivery of new therapies and biological agent-specific vaccines to the field. Furthermore, implementation of clinical and field trials during a public health emergency (PHE) 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 work and delivery of new therapies and vaccines to remedy the potential devastation of biological and chemical terrorism [40, 108].

### **7. Health security in the context of natural disasters**

The planet Earth is our home within the indifferent emptiness of the known universe. Always changing and evolving, the Earth is not a static environment. And while planetary changes (PCs) actively influence human activity and well-being, human civilization increasingly impacts the finely balanced planetary ecological and biophysical system [109]. 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 may be attributable to PCs. Earth's environmental disequilibrium has been evidenced in the contamination of drinking water supplies, pollution of its atmosphere, and increasing number of natural fires that significantly affect human health [110]. Moreover, the 1990–2016 Burden of Disease study mentions environmental factors such as climate change, food scarcity, unsafe sanitation, occupational exposure to chemical substances, population displacements, and conflicts as having significant impact on human health [111, 112].

Based on the above developments, a new definition of "health" has emerged as an extension of the health concept established in the 1946 Constitution of the World Health Organization: "Health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity" [113]. This updated definition includes not only the complete well-being of human civilization, but also the well-being of the environmental systems on which humans depend for sustainability [114]. Consequently, economic policies should balance economic development, social progress, human health, and environmental sustainability. Health professionals have an essential role in advocating for the preservation of Earth's socioeconomic and natural environments in order to protect the health of current and future generations [112, 115]. The following sections will describe some of the more important topics within this general theme.

*Volcanic events*: Volcanic eruptions and associated earthquakes pose significant health security risk(s). Destructive aspects of eruptions include explosions, hot ash release, melted ice, lava, and gas emissions [116]. These events inherently affect human activity and health as more than 500 million people live in close proximity to volcanoes [117]. Volcanic explosions can cause burns, death, and traumatic injuries, often in an unpredictable fashion [118]. Between 1900 and 2009, approximately 100,000 deaths and nearly 5 million people were affected by volcanic events, with primary causes of mortality being ash asphyxiation, thermal injuries from pyroclastic flow, and trauma [117, 119]. Lava flows can cause burns, death, destruction of critical health infrastructure, and loss of property/land. Volcanic ash exposure can lead to pulmonary complications (including acute respiratory distress, suffocation, and chronic lung disease), ocular injuries/infections, and cutaneous reactions [120–125]. 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 CO2H2S (carbon dioxide and hydrogen sulfide). These gases accumulate in low areas and are easily inhaled [116]. Several are colorless and odorless and can lead to respiratory distress, asphyxiation, and death. Volcanic ash containing crystalline silica can lead to pneumonoultramicroscopicsilicovolcanoconiosis and chronic lung disease. Volcano-associated earthquakes may cause structural damage and displacement [116]. Finally, there may be significant mental health sequelae (e.g., post-traumatic stress disorder or PTSD, and anxiety) [120–125].

Volcanic events have led to significant socioeconomic disruptions, affecting basic survival by negatively altering crops, livestock, water, heavy metal concentrations in the soil, and preventing access to healthcare [116, 126]. For example, the largest air transportation freeze since World War II occurred during the 2010 Icelandic Eyjafjallajökull eruption, where an estimated 107,000 flights were canceled during an 8-day period [127–129]. This single event affected nearly half of global air traffic, including 10.5 million stranded passengers and a staggering cost of \$1.7 billion [128, 129].

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Volcanic event readiness requires a comprehensive approach, which involves preparation, an emergency action plan, and a post-disaster plan. In an event of an eruption, communities should have an emergency kit ready in their homes [130]. Flashlights with extra batteries, first aid supplies, emergency food and water along with a manual can opener, essential medicines, shoes, breathing protection, and eye protection are all recommended by the CDC [131]. During an eruption, affected communities should adhere to evacuation instructions by local authorities. Understanding

local culture and customs aids in evacuation strategies, keeps emergency team members prepared, and allows for clear communication. Oftentimes, survivors of volcanic eruptions prefer to stay in their communities despite any future risk [132]. Consequently, avoiding harmful exposure is the most important strategy. Protective masks can prevent inhalation of ash particles and minimize respiratory symptoms if exposure is unavoidable. Although N-95 type masks are most effective, they can be poorly tolerated [133, 134]. Protecting eyes, removing contact lenses, and wearing clothing to cover open skin are among recommended measures [116]. Of importance, appropriate mitigation procedures should also be considered in case primary prevention measures fail. Post-disaster assistance and restoration will require internal and external cooperative efforts, and community involvement is critical. Teaching local community members how to treat burns, administer inhalers, provide oxygen, and give oral fluids for dehydration can greatly assist local health centers. Health-care providers in LMIRs will need to be adept at treating severe burns, preventing infec-

*Earthquakes*: Whether associated with volcanic events or isolated tectonic activity, earthquakes have a significant potential to impact local health-care capacity and health security, including the potential damage to hospitals, clinics, as well as possible disruptions to various political and social structures. When limited to smaller geographic areas or regions, the need for post-earthquake emergency surge capacity can be provided by nearby facilities that were not affected by the event. However, in cases of more widespread earthquake damage, or severe structural destruction that occurs within a geographically isolated area (e.g., as seen during the massive 2010 Haiti event), the damage to health-care infrastructure may reach sufficient magnitude to result in simultaneous threats to both public health (e.g., the ability to provide essential emergency medical services) and IHS (e.g., through secondary effects such as the possibility of population displacement, migration, and/or exacerbation of a preexisting conflict). Coordinated international relief action is

The fires in the Amazon rainforest of Brazil have been a source of great concern among the environmentalists and climate scientists [135]. However, the response of health-care professionals has been surprisingly muted despite the consensus that extensive Amazon fires may have far-reaching effects on human health and IHS. In fact, the current response is a far cry from our response to other health-care emergencies or epidemics. The reasons include reluctance to engage in a multistakeholder model of mitigating health-care concerns, the general acceptance of national health systems "existing in silos," and more generally the failure to appreci-

The major portion (~60%) of the Amazon, covering more than 2 million square miles in Brazil, is often called "the planet's lungs" and the carbon "sink" [136, 137]. In fact, it has been estimated that the Amazon is responsible for processing vast quantities of carbon dioxide and providing about 20% of the world's oxygen [138, 139]. Of importance, it is estimated that about 20% of the rainforest has already been lost,

ate the health-care implications of climate change taking place around us.

tion, and providing respiratory assistance to those in distress.

indicated under such conditions.

**7.1 Increased risk and impact of natural fires**

#### *DOI: http://dx.doi.org/10.5772/intechopen.93214 International Health Security: A Summative Assessment by ACAIM Consensus Group*

Volcanic event readiness requires a comprehensive approach, which involves preparation, an emergency action plan, and a post-disaster plan. In an event of an eruption, communities should have an emergency kit ready in their homes [130]. Flashlights with extra batteries, first aid supplies, emergency food and water along with a manual can opener, essential medicines, shoes, breathing protection, and eye protection are all recommended by the CDC [131]. During an eruption, affected communities should adhere to evacuation instructions by local authorities. Understanding local culture and customs aids in evacuation strategies, keeps emergency team members prepared, and allows for clear communication. Oftentimes, survivors of volcanic eruptions prefer to stay in their communities despite any future risk [132]. Consequently, avoiding harmful exposure is the most important strategy. Protective masks can prevent inhalation of ash particles and minimize respiratory symptoms if exposure is unavoidable. Although N-95 type masks are most effective, they can be poorly tolerated [133, 134]. Protecting eyes, removing contact lenses, and wearing clothing to cover open skin are among recommended measures [116]. Of importance, appropriate mitigation procedures should also be considered in case primary prevention measures fail. Post-disaster assistance and restoration will require internal and external cooperative efforts, and community involvement is critical. Teaching local community members how to treat burns, administer inhalers, provide oxygen, and give oral fluids for dehydration can greatly assist local health centers. Health-care providers in LMIRs will need to be adept at treating severe burns, preventing infection, and providing respiratory assistance to those in distress.

*Earthquakes*: Whether associated with volcanic events or isolated tectonic activity, earthquakes have a significant potential to impact local health-care capacity and health security, including the potential damage to hospitals, clinics, as well as possible disruptions to various political and social structures. When limited to smaller geographic areas or regions, the need for post-earthquake emergency surge capacity can be provided by nearby facilities that were not affected by the event. However, in cases of more widespread earthquake damage, or severe structural destruction that occurs within a geographically isolated area (e.g., as seen during the massive 2010 Haiti event), the damage to health-care infrastructure may reach sufficient magnitude to result in simultaneous threats to both public health (e.g., the ability to provide essential emergency medical services) and IHS (e.g., through secondary effects such as the possibility of population displacement, migration, and/or exacerbation of a preexisting conflict). Coordinated international relief action is indicated under such conditions.

#### **7.1 Increased risk and impact of natural fires**

The fires in the Amazon rainforest of Brazil have been a source of great concern among the environmentalists and climate scientists [135]. However, the response of health-care professionals has been surprisingly muted despite the consensus that extensive Amazon fires may have far-reaching effects on human health and IHS. In fact, the current response is a far cry from our response to other health-care emergencies or epidemics. The reasons include reluctance to engage in a multistakeholder model of mitigating health-care concerns, the general acceptance of national health systems "existing in silos," and more generally the failure to appreciate the health-care implications of climate change taking place around us.

The major portion (~60%) of the Amazon, covering more than 2 million square miles in Brazil, is often called "the planet's lungs" and the carbon "sink" [136, 137]. In fact, it has been estimated that the Amazon is responsible for processing vast quantities of carbon dioxide and providing about 20% of the world's oxygen [138, 139]. Of importance, it is estimated that about 20% of the rainforest has already been lost,

with the tipping point or "danger zone" for human well-being being not too far, at approximately 25% total rainforest capacity lost [140, 141]. 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 [141]. The current wave of Amazon fires represents the highest number of such events in nearly a decade, with a clear relationship to deforestation activity [142, 143].

Human effects attributable to tropical forest fires may be more pronounced than we think. In a more direct fashion, the respiratory system is exposed to various levels of smoke, with an associated presence of various volatile chemical agents [144]. This may contribute to both short-term and long-term pulmonary sequelae, including acute respiratory infections, chronic obstructive pulmonary disease exacerbations, and bronchial asthma [144, 145]. Emergency visits due to ocular exposures with resultant eye irritations have also been reported [145]. In another report, smoke exposures were associated with increased incidence of self-reported symptoms, medication use, outpatient and emergency room visits, hospital admissions, and mortality [146]. The strongest associations were noted between forest fire smoke exposure and asthma [146].

More indirectly, forest fires and the associated gradual climate change may also be affecting non-pulmonary organ systems. A recently published commentary proposes a potential link between chronic kidney disease of unknown origin (CKDu)—also known in Central America as Mesoamerican nephropathy—and greenhouse gas emissions [147]. The report is based on experiences with CKDu in El Salvador in the 1990s, when unusually large numbers of agricultural workers began dying from irreversible renal failure. The report finds the phenomenon to be pervasive among agricultural communities in hot, humid regions of Central America, suggesting an important contributory role of local climate characteristics [148, 149]. This may be further corroborated by reports of CKDu among sugarcane workers in Central America, who work, heavily clothed, in temperatures that frequently surpass 40°C (104°F) [148]. It has been proposed that CKDu may represent a form of heat-stress nephropathy that is associated with rapidly evolving environmental conditions [148, 150].

This important area of clinical investigation requires significantly more investment and resources so that we can better prepare for the consequences of environmental changes due to forest fires and global warming in general. Significant increases in severity and frequency of fires have been noted across the globe [151–155]. As health-care providers, we must venture beyond our traditional focus of medicine and therapeutics, and begin taking a more active role in advocacy, prevention, and mitigation. This will require multidisciplinary approaches that integrate elements of environmental science into clinical practice and public health [156, 157]. High-quality early warning systems should be developed to help protect vulnerable populations using "an epidemic prevention model strategy" employed in other areas of public health [158, 159]. Ample support must be provided for research into "climate-sensitive diseases" [160]. Appropriate rapid response capability should be integrated into public health systems around the globe.

#### **8. Nuclear incidents and health security**

Nuclear incidents can be broadly divided into military and civilian occurrences. Although military events (e.g., nuclear war, nuclear terrorism, and nuclear weapons testing) are of great importance in the overall contexts of potential modulation of planetary change, such scenarios are beyond the scope

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sources referenced herein [10, 161–165].

to various aspects of IHS.

noted among survivors [170, 171].

*International Health Security: A Summative Assessment by ACAIM Consensus Group*

of the current chapter. For completeness, we are directing the reader to other

The focus of this section will be on civilian nuclear occurrences. Within this subdomain, radioactive exposures can be broadly classified as either medical (e.g., health-care equipment used for radiation therapy, reagents used in nuclear medicine) [10, 166] or industrial (e.g., power generation, by-products of medical or military production, long-term storage of nuclear waste) [10, 167]. We will briefly discuss each of these—in fairly general terms—focusing on potential implications

Health-care related exposures tend to be contained to the immediate environment surrounding the area of radioactive contamination. One historical event of significance took place in Goiania, Brazil [166]. Another incident occurred in Indiana, Pennsylvania [166]. In both cases, injuries and mortalities were limited to a small number of directly affected individuals. Of importance, the Goiania incident involved negligent removal and disposal of 50.9 TBq of Cesium 137 from a radiotherapy unit [168]. Environmental contamination requires highintensity cleanup efforts, with generally acceptable results despite some degree of persistent residual radiation exposure risk [169]. Of note, post-event psychological and behavioral effects (termed "radiophobia" and similar to PTSD) were

In terms of industrial exposures, some of the most significant incidents involve the nuclear power plant explosion in Chernobyl, Ukraine (Former Soviet Union) [172] and the more recent nuclear reactor meltdowns at the Fukushima Daiichi Nuclear electric plant [173]. Both incidents exemplify the potential for long-term adverse effects of radioactive isotope releases on the immediate surroundings [174, 175], as well as the more remote, much subtler downstream exposures secondary to radioisotope concentration within the food chain [176–178]. In terms of the associated impact on IHS, various studies estimated long-term and longdistance effects of resultant radioactive releases [178–181]. Similar to medical radiation incidents, both social and mental health consequences have been noted among those exposed [182, 183]. Associations with medical conditions, including malignancies, appear to be less specific and weaker [184–186]. Appropriately administered food and contamination control programs are effective in minimizing the risk of internal radiation exposure [178, 187]. Of importance, governmental agencies such as the United States Nuclear Regulatory Commission are tasked with the oversight, nuclear safety framework, emergency planning, and appropri-

Health-care institutions have been increasingly aware of cyber health security (CHS) threats to our population and have taken measures to protect patients, visitors, and staff from such threats [188, 189]. Yet, despite this, the academic health-care community has been relatively slow to recognize and mitigate various cybersecurity threats [190]. Within this broad area of IHS, three aspects have been

• *Software supply chain attacks*: Attempts to infiltrate the information-technology (IT) infrastructure via a third-party vendor (e.g., EHR add-ons) or partner (e.g., HVAC) systems [191–193]. Symantec's 2018 Internet Security Threat Report found a 200% increase in supply chain attacks across all industry

ate protective actions as it relates to civilian nuclear incidents.

**9. Information and cyber health security**

identified as most important:

sectors [193].

#### *DOI: http://dx.doi.org/10.5772/intechopen.93214 International Health Security: A Summative Assessment by ACAIM Consensus Group*

of the current chapter. For completeness, we are directing the reader to other sources referenced herein [10, 161–165].

The focus of this section will be on civilian nuclear occurrences. Within this subdomain, radioactive exposures can be broadly classified as either medical (e.g., health-care equipment used for radiation therapy, reagents used in nuclear medicine) [10, 166] or industrial (e.g., power generation, by-products of medical or military production, long-term storage of nuclear waste) [10, 167]. We will briefly discuss each of these—in fairly general terms—focusing on potential implications to various aspects of IHS.

Health-care related exposures tend to be contained to the immediate environment surrounding the area of radioactive contamination. One historical event of significance took place in Goiania, Brazil [166]. Another incident occurred in Indiana, Pennsylvania [166]. In both cases, injuries and mortalities were limited to a small number of directly affected individuals. Of importance, the Goiania incident involved negligent removal and disposal of 50.9 TBq of Cesium 137 from a radiotherapy unit [168]. Environmental contamination requires highintensity cleanup efforts, with generally acceptable results despite some degree of persistent residual radiation exposure risk [169]. Of note, post-event psychological and behavioral effects (termed "radiophobia" and similar to PTSD) were noted among survivors [170, 171].

In terms of industrial exposures, some of the most significant incidents involve the nuclear power plant explosion in Chernobyl, Ukraine (Former Soviet Union) [172] and the more recent nuclear reactor meltdowns at the Fukushima Daiichi Nuclear electric plant [173]. Both incidents exemplify the potential for long-term adverse effects of radioactive isotope releases on the immediate surroundings [174, 175], as well as the more remote, much subtler downstream exposures secondary to radioisotope concentration within the food chain [176–178]. In terms of the associated impact on IHS, various studies estimated long-term and longdistance effects of resultant radioactive releases [178–181]. Similar to medical radiation incidents, both social and mental health consequences have been noted among those exposed [182, 183]. Associations with medical conditions, including malignancies, appear to be less specific and weaker [184–186]. Appropriately administered food and contamination control programs are effective in minimizing the risk of internal radiation exposure [178, 187]. Of importance, governmental agencies such as the United States Nuclear Regulatory Commission are tasked with the oversight, nuclear safety framework, emergency planning, and appropriate protective actions as it relates to civilian nuclear incidents.

## **9. Information and cyber health security**

Health-care institutions have been increasingly aware of cyber health security (CHS) threats to our population and have taken measures to protect patients, visitors, and staff from such threats [188, 189]. Yet, despite this, the academic health-care community has been relatively slow to recognize and mitigate various cybersecurity threats [190]. Within this broad area of IHS, three aspects have been identified as most important:

• *Software supply chain attacks*: Attempts to infiltrate the information-technology (IT) infrastructure via a third-party vendor (e.g., EHR add-ons) or partner (e.g., HVAC) systems [191–193]. Symantec's 2018 Internet Security Threat Report found a 200% increase in supply chain attacks across all industry sectors [193].


In February 2013, President Obama issued an Executive Order on Improving Critical Infrastructure Cybersecurity, with the goal of improving cybersecurity and reducing cyber threats to the nation's "critical infrastructure sectors," including the Healthcare and Public Health Sector [201]. The Executive Order defines "critical infrastructure" as "systems and assets, whether physical or virtual, so vital to the United States 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" [201]. In other words, the executive order and other governmental policies collectively identify health-care systems and assets as so vital to the U.S. that their impairment would severely threaten public health and safety.

Many medical devices and other hospital assets now have direct access to the Internet—both in an encrypted (e.g., secured) and unencrypted (e.g., unsecured) fashion [202, 203]. Billing systems use electronic financial transfers, medical devices upload vital statistics in real time to EHRs, hospitals allow patients and visitors access to hospital WiFi as a courtesy, and patients are being provided access to protected health information (PHI) via authentication on the Internet—all of these are important and vital aspects of a modern hospital ecosystem [204–207]. As hospitals benefit from networked technology and greater connectivity, they also must ensure that they evaluate and manage these new risks. The American Hospital Association has identified the following priorities [208, 209]:


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**benefits and threats**

*International Health Security: A Summative Assessment by ACAIM Consensus Group*

possible in the changing cyber threat environment.

to learn more about the CS risks faced by hospitals.

coverage is adequate and appropriate given CS risks.

(and certainly not impeding) helpful content [9, 211].

3.Investigate the medical devices used by the hospital in accordance with the June 2013 FDA guidance to ensure that the devices include intrusion detection and prevention assistance and are not currently infected with malware.

4.Review, test, evaluate, and modify, as appropriate, the hospital's incident response and data breach plans to ensure that the plans remain as current as

5.Consider engaging in regional or national information-sharing organizations

6.Review the hospital's insurance coverage to determine whether the current

The role of social media platforms in IHS is substantial, and is likely to continue to grow [210]. There are certainly many positive aspects of social media (SM), such as the ability to quickly conduct population-level education, surveillance, and even preventive interventions [210]. At the same, there is the "dark side" potential of subverting these powerful platforms to both passively and actively facilitate harm and to disseminate misinformation [9]. Among the most challenging aspects of SM platform 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

The role of SM as a potential agent for dissemination of harmful medical misinformation tends to be underappreciated and/or intentionally minimized. Yet this health security threat is not only global but also represents a more pervasive form of harm, where incorrect, erroneous, or outright dangerous information becomes "entrenched" within the population's collective mind. A hypothetical example of medical misinformation may appear as follows, "all those who wash hands with alcohol solution expose themselves to deadly mutations and cancers." When disseminated widely, through a combination of "likes" and "upvotes," this dishonest and extremely harmful information may reach the status of "accepted reality" where people blindly 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

In one real-life example where cultural norms, religious beliefs, and SM reinforcement played an important role in adversely influencing health security, the reluctance to comply with modified burial practices may have contributed to ongoing spread of Ebola virus during the 2014–2015 outbreak [24, 213]. In another instance, support for SM-based conspiracy theories around the Ebola pandemic abounded, while changes in infection prevention practices appeared to be lagging the dissemination of correct health information [25]. Finally, the unethical opportunism of false promises and exploitation of the naïve was highlighted by the emergence of unsubstantiated and harmful claims of "disease-modifying behaviors" that may actually lead to significant morbidity and/or mortality [213, 214], whether intentionally or not. 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" [9]. At the governmental level, various organizations and agencies actively

population-level manifestations such as public anger and civil unrest [212].

**10. Global communication platforms and social media: balancing** 

*DOI: http://dx.doi.org/10.5772/intechopen.93214 International Health Security: A Summative Assessment by ACAIM Consensus Group*


### **10. Global communication platforms and social media: balancing benefits and threats**

The role of social media platforms in IHS is substantial, and is likely to continue to grow [210]. There are certainly many positive aspects of social media (SM), such as the ability to quickly conduct population-level education, surveillance, and even preventive interventions [210]. At the same, there is the "dark side" potential of subverting these powerful platforms to both passively and actively facilitate harm and to disseminate misinformation [9]. Among the most challenging aspects of SM platform 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 (and certainly not impeding) helpful content [9, 211].

The role of SM as a potential agent for dissemination of harmful medical misinformation tends to be underappreciated and/or intentionally minimized. Yet this health security threat is not only global but also represents a more pervasive form of harm, where incorrect, erroneous, or outright dangerous information becomes "entrenched" within the population's collective mind. A hypothetical example of medical misinformation may appear as follows, "all those who wash hands with alcohol solution expose themselves to deadly mutations and cancers." When disseminated widely, through a combination of "likes" and "upvotes," this dishonest and extremely harmful information may reach the status of "accepted reality" where people blindly 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 such as public anger and civil unrest [212].

In one real-life example where cultural norms, religious beliefs, and SM reinforcement played an important role in adversely influencing health security, the reluctance to comply with modified burial practices may have contributed to ongoing spread of Ebola virus during the 2014–2015 outbreak [24, 213]. In another instance, support for SM-based conspiracy theories around the Ebola pandemic abounded, while changes in infection prevention practices appeared to be lagging the dissemination of correct health information [25]. Finally, the unethical opportunism of false promises and exploitation of the naïve was highlighted by the emergence of unsubstantiated and harmful claims of "disease-modifying behaviors" that may actually lead to significant morbidity and/or mortality [213, 214], whether intentionally or not. 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" [9]. At the governmental level, various organizations and agencies actively

work on responses and countermeasures to disinformation present across various media platforms, including the National Security Communications Team in the United Kingdom, the National Cyber Directorate in Israel, the National Cybersecurity Agency in France, and the Australian Security Intelligence Organization, among others.
