It’s true. Making sure the nation has the drugs, vaccines, and medical devices needed to protect health in an emergency requires more money, authority, and technical expertise than any one federal agency has alone. But by collaborating, federal agencies are making it happen. Take the Ebola outbreak as a recent example.
As the Ebola outbreak spread to multiple countries in West Africa and became a public health emergency of international concern, federal agencies in the United States pulled together to review quickly, the vaccines, diagnostics, and therapeutics the agencies were supporting. Collectively known as medical countermeasures, these products were in various states of early development; none had reached clinical trials.
The agency representatives made fast decisions about how to use the authority, funding, and technical expertise from each agency to move as many products, as rapidly as possible, into clinical trials and get them into the hands of doctors and patients to prevent or treat this deadly infection.
That collaboration, speed and empowerment is the beauty of the Public Health Emergency Medical Countermeasure Enterprise, or PHEMCE. In one way or another, all of the agencies involved in the PHEMCE, support the development of medical countermeasures for military or civilian use or both.
This group plans together to be sure that development takes place as fast as possible without funding redundant efforts, and that there aren’t gaps in addressing health threats from chemical, biological, radiological or nuclear agents. That’s where the PHEMCE Strategy and Implementation Plan come into play.
Like all strategies, the PHEMCE Strategy and Implementation Plan published this month identifies goals and objectives. This one also describes the activities and programs these agencies will undertake to have the medical products our nation will need when confronted with health threats from chemical, biological or rad/nuc incidents, whether from bioterrorism or naturally occurring incidents like this current Ebola epidemic.
The Strategy and Implementation Plan becomes a business plan that these agencies follow in the near-term and long-term to make the best use of available resources to enhance national health security.
Through the PHEMCE, HHS was able to estimate the funding requirements for NIH, ASPR, FDA, and CDC to pursue medical countermeasure development and purchase in fiscal years 2014-2018, and provided this information to Congress. Agency-specific spending in these years is estimated to be: NIH/NIAID - $9.2 billion; ASPR/BARDA - $5.0 billion; CDC/SNS - $3.1 billion; and FDA - $13.7 million. The out-year funding estimates (FY 2017 & 2018) included in the report were developed without regard to the competing priorities that are considered in the annual development of the President’s Budget and must be considered as budget submissions to Congress are developed in these out-years. So these estimates are subject to change in the future.
The Strategy and Implementation Plan also evaluates progress against the group’s previous priorities, describes progress in developing products to meet the medical needs of at-risk populations, summarizes the development that’s underway, and outlines what’s been purchased by the agencies and now available to local communities in a public health emergency.
The drugs, vaccines, and medical devices doctors prescribe or use every day require years, often decades, to develop, and private industry spends billions of dollars bringing these products to market. For each product that reaches the market, eight others failed because the science just didn’t work. Developing products needed for public health emergencies can be even more difficult.
Yet, by collaborating through the PHEMCE, federal agencies have made tremendous progress. More than 160 products have reached advanced development stages; a dozen types of products have been added the Strategic National Stockpile in just eight years, and since 2012, FDA has approved eight new products from our pipeline. These products will help combat pandemic influenza viruses and other emerging infectious diseases, anthrax, smallpox, botulism, radiological and nuclear events, and chemical nerve agents.
To ensure the safest and most effective use of limited medical countermeasures following an attack, PHEMCE partners developed up-to-date clinical guidance for using anthrax countermeasures in children, pregnant women, and the general population under mass casualty conditions. They did the same for products that would be used in a mass casualty incident involving botulism or to treat blood-related injuries after a radiological or nuclear incident.
That’s just a snapshot. Learn more about what’s being done under the 2014 PHEMCE Strategy and Implementation Plan.
The Biomedical Advanced Research and Development Authority (BARDA) today took an exciting next step in implementing a three-prong strategy to develop, manufacture, test, and make available Ebola monoclonal antibody therapeutic candidates as part of the U.S. Ebola response. BARDA now is partnering with Medicago and Fraunhofer to produce Ebola monoclonal antibodies similar to ZMapp from Mapp BioPharmaceuticals to study efficacy in nonhuman primates and then potentially for clinical studies in humans.
These studies will help to determine whether Ebola monoclonal antibodies produced by other tobacco biopharmaceutical companies are as effective as ZMapp. ZMapp is now entering clinical trials in West Africa. If they are as effective, the U.S. could increase the overall manufacturing capacity for ZMapp and similar products.
Medicago is a Canadian company that develops and produces plant-based vaccines and therapeutics; Fraunhofer is a non-profit research and development organization. They will utilize their own proprietary tobacco expression systems in producing the antibodies, which will be compared to ZMapp. BARDA is collaborating with the Department of Defense using existing DoD contracts with Medicago and Fraunhofer to expedite the manufacturing of the product for use in studies and to conduct the animal studies.
BARDA has taken other steps to implement the three-prong strategy:
- Supporting Mapp BioPharmaceuticals in developing and manufacturing ZMapp for clinical trials.
- Partnering with Regeneron and Genentech to develop and manufacture new Ebola monoclonal antibodies using specialized CHO mammalian (Chinese hamster ovary) cell lines for nonhuman primate studies and potentially clinical studies.
Together these three prongs will help make safe, effective therapeutics – known as monoclonal antibody therapeutics – available as quickly as possible in the ongoing fight against Ebola. Since the beginning of the Ebola outbreak in West Africa, BARDA has been working with our private industry partners to explore all possible means to speed development and production of therapeutics and vaccines. We are leaving no stone unturned.
BARDA and its partners are coming closer to bringing new drugs to market to help in the fight against antibiotic resistance. Four of BARDA’s partners have met major milestones in the development of new antibiotics, and with increased funding, BARDA is poised to further strengthen the antibiotic pipeline.
Two of these drugs could be coming to market soon and both of them may be able to overcome antibiotic resistance that is threatening existing classes of drugs. The first new product is eravacycline, which was developed by Tetraphase Pharmaceutical to treat complicated intra-abdominal infections (cIAI). The second is solithromycin, an experimental antibiotic by Cempra Inc. that would be used the treatment of patients with community acquired bacterial pneumonia (CABP). Both of companies are working toward filing a new drug application (NDA) with the FDA in late-2015. If their applications are approved, they would become available for sale in the commercial market.
Two more BARDA-sponsored antibiotics to fight Gram negative infections also have met major milestones. BARDA is working with Rempex Pharmaceuticals on two global Phase 3 studies of Carbavace. One set of Phase 3 trials centers around its use in combatting complicated urinary tract infections and acute pyelonephritis, a common but serious kidney infection.
In addition, BARDA has been working with Achaogen Inc. since 2010 on the development of a novel aminoglycoside, plazomicin. Aminoglycosides are a group of bactericidal antibiotics that inhibit bacterial protein synthesis. Achaogen has successfully moved this program into Phase 3 clinical development and has enrolled its first patient in clinical trials.
The President’s FY16 budget included a request for $1.2B in increased funding to address antimicrobial resistance. Several government agencies would be recipients of that increased funding, including BARDA. If approved, BARDA would use this funding to support new antibacterial therapeutics and diagnostics to combat bacteria that pose a threat to national security and public health - especially multi-drug resistant bacteria.
By working together, BARDA and its partners are poised to give hospitals and healthcare providers new options that can help them address a wide range of bacterial infections that are serious every day, but that can be particularly dangerous during an emergency when hospitals and healthcare systems are stressed. We are very proud of our partnerships with these companies and excited by the milestones that they are meeting that could play an important role in protecting health. By continuing to work with our partners, we can fight antibiotic resistance with next-generation drugs during disasters and every day.
The recent nationwide shortage of injectable solutions, such as normal saline and Lactated Ringer's (given intravenously to a patient to replace fluids and electrolytes lost from illness or injury), illustrates how a resource shortage can lead to a need to ethically allocate available resources.
At the local level, the decision is usually made on a case-by-case basis. For example, if a hospital has two patients, both of whom need the same resource – like saline or a ventilator – and only one resource is available, a medical provider or small group of providers (often with input from the patient’s family) determines which patient should receive the needed care, medicine or equipment.
They also determine what alternative treatment can be used for the other patient until the ideal treatment is available. It may be a matter of minutes or hours, or could be a matter of days, depending on the nature of the resource and what caused the shortage. It can be very difficult to make an allocation decision on a day to day basis, but it’s even more difficult in a catastrophic disaster. In a catastrophic situation healthcare providers won’t have time to consult with each other and ask the family; no one else may be available to ask.
Hospitals, healthcare facilities and state and local planners need to start engaging their community members now so that they can work together to decide how these difficult decisions will be made. So if (or when) the time comes, members of the community understand how medical resources and other emergency management resources (fire, rescue, law enforcement, etc.) will be used. By engaging community members before an event occurs, they may be more likely to see the process as a legitimate one and they may better understand how actions that they take in an emergency can impact their health or the health of their loved ones.
The federal government can provide additional personnel and medical supplies in catastrophic situations yet like all other resources, ours are finite, too. And like every community, we too need a protocol – a way of making decisions about where to send the resources we have available and help communities save as many lives as possible.
ASPR coordinates the public health and medical resources available through the federal government to support states and communities in emergencies. A participant in the 2011 drill noted that ASPR has no protocol to make allocation decisions when the demand for federal support exceeds the supply of resources.
A lot of factors are involved in figuring out how to allocate resources. In planning for it, all levels of government have to think about the effects of a catastrophic event on transportation because this affects how and where resources can be transported into the area and set up, and on how those resources can be supported (the responders need a place to stay, food, and water, and they will need medical resupply). It will matter where those resources are located: have any been affected by the disaster? Are any cut off from getting to the affected area?
Other considerations include whether there are active response operations going on, or if it's a time of year when we know disasters such as tornados or hurricanes are likely to occur which could create additional requests for those same resources.
Unlike the decisions commonly made in an emergency room, decisions about how to respond in a catastrophic situation go beyond the needs of one or two patients. In deciding how to respond to such a catastrophic disaster, medical providers, emergency managers and leaders at all levels of government cannot use the same model of medical ethics that a doctor would turn to when deciding which patient should get the ventilator. The decisions have to consider the public health needs of a significant portion of the country's population.
So ASPR's Office of Emergency Management developed a framework for the type of ethical decision-making required in catastrophic situations when resources are scare nationwide or possibly even worldwide. The framework is only for federal public health and medical resources. It could be a model for your state or your community.
This blog is the first in a series on the allocation of scarce resources in a disaster. We'll discuss the framework and processes in future blogs. To learn about new posts to the ASPR Blog and other topics related to public health emergency preparedness, response and recovery, follow us on Twitter or like us on Facebook.
Has your community already started one of these crucial conversations? If so, share your community’s story in a comment to this blog post. Let us know what worked, what didn’t, and how this discussion impacted your community.
Many parts of the country get snow and ice from time to time, so winter weather can seem like it is no big deal. And that is part of what makes winter storms so dangerous. But downed power lines, icy roads, power failures, and exposure to cold weather can all have serious health consequences.
If you know what to look for and plan in advance, you have a better chance of staying healthy and helping those around you weather the storm. Here are a few things that you can do:
- Plan with family, friends and neighbors before the storm strikes: Knowing who you can count on – and who is counting on you – can help protect everybody’s health. Before a storm, start a conversation on how you will help each other. You can plan to stay in touch during and after the storm through social networking sites, by texting or by knocking on your neighbor’s door. When disaster strikes, phone lines may be jammed, but texts may get through. Remember to charge your phone before a storm and have a backup power supply charged and ready.
- Stock up on food, water, medicine and supplies for your car: Power and water outages are common in a winter storm and roads may be unsafe. So make sure that you have the food, water, medicines, and first aid supplies to help you get through the storm. Also make sure that you have the basic safety equipment for your car, including a full gas tank, shovel, windshield scraper, and emergency kit for the car. For a detailed checklist of supplies, see CDC’s Winter Weather Checklists.
- Stay tuned to your local news and listen to state and local officials: When winter storms strike, your local news station and your state and local officials will be able to provide you with the information you need to stay safe and healthy.
- Stay safe in a power outage: During a power outage, never use generators, grills, or other gasoline-, propane-, or charcoal-burning devices inside your home, garage, or carport or outside near doors, windows, or vents. They produce carbon monoxide and fumes can kill. Be sure that you know how to use generators safely and follow the manufacturer’s instructions before starting them up. Food safety is also a common issue in power outages. If you are trying to figure out what to keep and what to toss, don’t guess. Use these charts to learn when to toss refrigerated and frozen foods.
- Plan for chronic conditions: When disaster strikes, many people with chronic conditions end up in hospitals because they need care and don’t have anywhere else to go. If you suffer from a chronic condition, talk to your doctor about preparedness. If you rely on refrigerated drugs, make sure you know what you would do if the power goes out. If you rely on dialysis, try scheduling dialysis early, be sure that you know where to find an alternate facility, and that you have taken other steps to prepare for emergencies. If you rely on electrically powered medical equipment, like an oxygen concentrator, make sure you know how to find the spare battery and charge it in case of a power outage.
- Be a bystander who doesn’t stand by: Winter storms can put people at risk for everything from hypothermia to injuries, causing hospitals may be overcrowded and EMS may be unable to reach people quickly given road conditions. So learn the signs of frostbite and hypothermia and what to do when someone is exhibiting those signs. Injuries are also very common during winter storms, and learning first aid and CPR could save a life.
When winter weather comes, we hope everyone stays safe and healthy. Taking the time to prepare before an emergency strikes could help keep you, your family and even your community bounce back faster.
Children comprise more than a quarter of the U.S. population and account for a fifth of all hospital emergency department visits. Yet in 2013 when the National Pediatric Readiness Project assessed approximately 5,000 U.S. emergency departments, less than half of the 82 percent of hospitals that responded reported having written disaster plans addressing the specific needs of children.
The physical and psychological needs of children in disasters aren’t the same as those of adults, and healthcare workers need specific training and equipment to provide this care on both a day-to-day basis as well as during a disaster. Now there’s a tool to help healthcare facilities plan for children’s unique health needs in disasters.
Treating children requires clinicians to have different sized equipment and training in order to perform the procedures needed in an emergency situation, for example, to start IV-lines or ventilators. Pediatric patients require different medication dosages, and they have different health needs based on age, height, weight and emotional development. Young children tend to be less verbal, yet children of all ages are often more fragile and more affected by the stress of disasters than adults and often display these effects in different ways than adults. Disasters can take a heavy toll on a child’s development if not handled with care.
There are legal implications, too, that need to be considered in disasters. Children can’t consent to their own care, so parents and children may need to be treated in the same hospital to avoid the legal and emotional issues that result from separation. Hospital planners also need to consider that parents may not be willing to be treated in a different hospital than their children. Communities face similar dilemmas in planning for evacuation since children’s needs in emergency shelters differ from adults’ and must be considered in advance.
Medical surge also presents very differently for children than for adults. Surge may require that providers who don’t usually treat children do so in disasters. This possibility is important to account for in all surge planning. In addressing surge capacity for children’s care, one approach communities could take is to identify tiers of hospitals that treat pediatric patients as well as adults. Working as part of healthcare coalitions, hospitals can distribute resources and patients to support the community effectively and cost-efficiently.
To help hospitals and communities plan for such differences, ASPR worked with the HHS Health Resources and Services Administration (HRSA) and the HRSA Emergency Medical Services for Children (EMSC) Program to create a unique checklist to address pediatric domains to support hospital administrators and leaders when trying to incorporate pediatrics into their existing disaster plans; it is available as an interactive or downloadable tool.
The team consulted with a wide range of subject matter experts (SME’s) to develop consensus on ten essential domains of pediatric planning that should be incorporated into disaster policies for all hospitals. Then they identified and built on existing resources to create a checklist to help administrators and clinical leaders incorporate pediatric elements into hospital disaster plans. The team even incorporated real-world experiences, like New York University Hospital’s experience evacuating neo-natal patients after Hurricane Sandy.
To help promote the needs of children in disasters, the team included an online compendium of resources related to medical and public health issues for children in disasters and emergencies. Then they pilot tested the new tool.
Let’s move the dial from less than 50 percent to 100 percent of hospitals and healthcare facilities planning for the needs of children in disasters. The next level, of course, is to exercise those plans.
Has your facility cared for children and families in disasters? If so, share your best practices and lessons learned by commenting on this blog.
“Everybody can be great because anybody can serve....You only need a heart full of grace. A soul generated by love. And you can be that servant.” - Dr. Martin Luther King, Jr.
Each time that individuals unite to help others, a step is taken to make Dr. Martin Luther King, Jr.’s dream for a better world come true. Volunteer service is a great way to serve our communities and help make that dream a reality.
Millions of people throughout the country will participate in Dr. King’s legacy on January 19, 2015 as part of this year’s Martin Luther King, Jr. Day of Service. This service day is part of United We Serve’s national call to service initiative and honors Dr. King’s life and ideals by empowering individuals throughout the nation to work together to serve the needs of the community through volunteerism.
Volunteers can dedicate their time and skills to help ensure that their communities are more resilient by volunteering with programs like the Medical Reserve Corps (MRC). The MRC is a national network of locally based and run groups of volunteers, organized and committed to strengthening public health, improving emergency response capabilities, and building the resiliency of their communities. It is a great example of people united from all walks of life that have a variety of skills, experiences, and backgrounds but unified by their mission.
Local MRC units and their volunteers are trained and work within their community’s local health, preparedness, and response infrastructure to be available to ensure there is a sufficient medical surge capacity and workforce in the event of an emergency. MRC volunteers also promote preparedness and serve as public health ambassadors to their communities in order to help reduce potential risks and vulnerabilities in their communities should an incident occur.
The Martin Luther King, Jr. Day of Service is a great reminder to take a day, give back, and make a difference in our communities! However, volunteering is something that we can do throughout the year as well. The MRC is a great opportunity to get involved with the local community to make it more resilient, safe, and healthy.
For more information about volunteering or partnering with the MRC, please visit http://www.medicalreservecorps.gov. To learn more about Martin Luther King, Jr. Day of Service, visit http://www.nationalservice.gov/special-initiatives/days-service/martin-luther-king-jr-day-service-0.
We often hear that natural disasters are stressful and, in public health, we recognize that people may have difficulty coping. It’s easy to see why. Homes, businesses, daycares, healthcare facilities and doctors’ offices are physically destroyed. Impacts on the local economy and personal financial stability are visible. What we don’t often consider is that disease outbreaks can be just as stressful and that coping may be just as difficult. The unknown or unfamiliar nature of diseases breeds fear and concern that hold very real consequences for our communities. Distress and concern, if unaddressed, can lead to unneeded quarantine directives and income loss, as well as unnecessary medication purchases or surges in emergency room visits.
After the emergence of Severe Acute Respiratory Syndrome (SARS) in 2005 and of the H1N1 flu in 2009, researchers and practitioners examined the psychological impacts on patients who were quarantined. These patients expressed feelings of anger, sadness, guilt, loneliness, and fear for the welfare of friends and family. In addition, patients worried that they would lose income due to quarantine and that their contacts, families, and friends would be stigmatized. These concerns are now being expressed by health professionals working on the front lines to combat Ebola.
These emotions and their consequences must be considered as public health agencies and health care professionals talk about a new or emerging disease. Leveraging risk communication can help. Risk communication research demonstrates the importance and effectiveness of addressing fear and concern. The research shows that unless we address the emotions tied to the situation, the scientific facts will be ignored.
During the 2009, H1N1 outbreak, the National Preparedness and Response Science Board (formerly the National Biodefense Science Board) provided guidance and recommendations for public health agencies on how to integrate behavioral health into interventions and how to address communication and messaging around pandemic flu for the public. These recommendations aligned with decades of research into the practice of risk communication and remain relevant today.
The board’s recommendations included:
- Provide messaging to reduce stigmatization of groups as needed, and utilize trusted community and faith-based leaders to help promote healthy behaviors
- Take into account factors such as culture and ethnicity, age, disability, and medical conditions (including serious mental illness and pharmacologically dependent)
- Maintain sensitivity to terminology and need for actionable guidance
- Discourage use of imprecise term “worried well”
- Provide a short explanation of why people are being asked to refrain from usual behavior and tell them what action to take instead
Public health and healthcare professionals can move risk communication principles and this advisory board’s expert recommendations into practice not only by informing and advising the public on protecting health, but also by acknowledging and normalizing the emotional response to the situation, including an infectious disease outbreak. When we are anxious, worried, or scared, our bodies and thought processes don’t perform optimally; we’re less able to process instructions, follow directions, or even remember that we received information on what to do.
When our fears and concerns are acknowledged, we immediately want to know what our community leaders are doing to protect us now and in the future and – just as important – what we can do to protect ourselves, have a voice in decisions that impact us, and feel in control of the situation. This information, too, helps support the behavioral health of our patients, family, friends, the community and the nation.
Among the most important elements in helping people “get the message” is listening. Incorporating what we learn through psychological first aid into our communications can help. The World Health Organization provided recommendations based on the principles of Psychological First Aid which reflects the emerging science on how to support people in the immediate aftermath of extremely stressful events.
Offering psychological first aid means that we look to check for serious distress reactions; ask about needs and concerns; actively listen; help people address basic needs and access services; give actionable information, and connect people with loved ones and social support.
By identifying the behavioral health concerns of disease outbreaks and acknowledging and addressing these concerns in the way we communicate, public health and health care professionals can make an important impact on the way the community copes with the situation. We can help community members make sound decisions, protect health and, overall, boost our community’s resilience.
Want to know more addressing the psychological impacts of diseases? Check out this video webcast on the Psychological Impact of Pandemics made during the H1N1 pandemic.
Are people in your community stressed about Ebola? Refer them to the Disaster Distress Helpline, 1-800-985-5990. The HHS Substance Abuse and Mental Health Services Agency offers a wealth of other resources, too, from tips to training to a cell phone app.
Our nation achieved a milestone in preparing for pandemic influenza with the FDA approval Friday of Rapivab (peramivir) to treat acute, uncomplicated influenza infection in adults 18 years and older.
Rapivab is the third neuraminidase inhibitor approved by the FDA to treat flu infection, but the first approved in an IV formulation that can be administered in a single dose. This distinction is important for patients who may be unable to swallow pills or inhale a medication.
BARDA has long recognized the need to have antiviral drugs readily available for the treatment of influenza. Each year 5-20 percent of the U.S. population develop seasonal flu and could benefit from antiviral treatment. During influenza pandemics, the number of people who become ill can increase rapidly before an influenzavaccine is available and frequently exceeds 25 percent of the total population. Having effective antiviral drugs readily available is a pillar of our preparedness for such public health emergencies.
Neuraminidase inhibitors are commonly used to treat flu infection. These drugs inhibit an enzyme called a neuraminidase, which releases viral particles from infected cells so the virus cannot infect the body’s uninfected cells. This means your body can fight the infection faster and reduces the time and severity of flu symptoms.
So beginning in 2007, we awarded a $234.8 million contract to BioCryst in 2007 to develop peramivir for use in pandemic influenza infections. The safety data collected under this development program allowed FDA, during the 2009 H1N1 pandemic, to issue the first Emergency Use Authorization in its history for an unapproved product to treat patients with severe influenza.
The drug becomes the 15th product sponsored by BARDA to earn FDA approval to prevent, diagnose or treat influenza. That’s tremendous progress in less than 10 years. We are proud to have supported development of this influenza therapeutic and so many others to help meet the needs of influenza-infected patients during a public health emergency and every day
As we are in the throes of the season of giving, we consider all the ways we can contribute – to our families, places of work, and communities. We reflect on the past year and look ahead to a new beginning. It is the time to consider ways to improve and grow in the future. One way that we can do that is through service. This year, we saw struggles with natural and public health events, including the Oso Mudslide and Ebola. In the midst of crises, there are those who step up to serve. These are the the backbone to communities’ resilience. Whether an emergency response or on-going work to support the health of a community, volunteers give their time, expertise, and heart.
The Medical Reserve Corps (MRC) offers an outstanding opportunity to help keep your community healthy, safe and strong. The MRC is a national network of units made up of medical and public health volunteers, as well as others, with a mission to improve the public health, emergency response, and resiliency of communities.
Volunteers assist in many roles, including communications, logistics, safety and training. MRC teams help promote everyday health as well as volunteering during disasters. They teach people how to develop a family preparedness plan, provide screening for high blood pressure and diabetes, vaccinate members of their communities against the flu, and so much more. No matter the size of the disaster or the magnitude of the crisis, it is the first responders and the local volunteers that understand the needs, know the lay of the land, and are there from the first call to the end of recovery. They are the ones there between the disasters, caring for their neighbors, and providing the on-going - and sometimes unrecognized - support that is needed to keep the towns, cities, and counties in good health.
Through the efforts made every day to improve the lives of those around them, people in the MRC and other volunteer organizations are reducing risk and increasing the capability and capacity of a community to bounce back from tragedy. As we look to the future, we take from the success of the past, as well as the shortfalls, to build our skillsets, strengthen our capabilities, identify our needs, train to better respond, and create communities of health and resilience.
When you now think of how and where you can give, consider volunteering. In fact, those who give find themselves happier and healthier. So you might just find yourself the recipient of more joy in 2015 when you make the time to give. The best part is that anyone can volunteer. There is a role and a place for every person that wishes to share of themselves. It is important to remember during this busy and often overwhelming time of year that giving is not always monetary and that often, the greatest presents are from the heart and handmade. With that said, I ask you, what better gift could you give than your time and expertise as a volunteer?