Last Page Update: 3.28.24
Status
Active Recovery
Date
January 30, 2020
Region
Global
Globally, COVID-19 deaths have far exceeded 6 million (and much higher according to the World Health Organization). The global public health emergency has officially ended. COVID may seem done for many, but COVID is not done with us yet, no matter how badly we want it gone. COVID is still sickening and killing people around the world (nearly 10,000 deaths in the last month of 2023). As new variants/subvariants appear, vaccines work to limit the worst of COVID, especially for the most vulnerable. Even if you are fully vaccinated (including boosters), remain vigilant. When in doubt, mask up. And get the shot if you have not. (source: JHU)
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We focused on frontline health workers from the beginning. More than 180,000 (est. from WHO) died and probably many more in the Global Pandemic, and burnout among health workers raises longer-term concerns. Keeping them healthy, even after the ending of the Pandemic, is critical so they can continue to do life-saving work for low-income patients in need of essential health services and ongoing care. Many live in and serve communities that are vulnerable to a daily and deadly inequality, especially in access to health care. We have provided mental health support for health workers pushed to and beyond their limits. Health worker burnout threatens already over-burdened health systems, including the U.S. We all can help health workers who put their lives on the line to keep us safe by getting vaccinated. Caring for health begins with caring for each other.
The Facts
The COVID-19 outbreak, first reported in Wuhan China in December 2019 exploded into a Global Pandemic within weeks. After four years of a Pandemic, as many put aside preventive measures, vaccines have saved many lives. The science keeps learning more, but at the same time, so does the virus. Stay informed. Stay vigilant. Scroll down, get the facts and learn more.
After four years of COVID-19, with the global emergency over, COVID-19 has not gone away. It has just entered an endemic phase, which means that the virus will continue to circulate indefinitely. New variants arise. It is still a significant risk for older adults as they represented 90% of the deaths in the U.S. from COVID in 2023. Ageism has long been a problem in American society, but it spiked during the Pandemic. Overall, more than 1.18 million people have died in the U.S., many more millions around the world, and people continue to sicken and die from COVID-19. Many of the losses could have been avoided especially among the elderly.
One thing we have learned is the value of information we can trust. Misinformation is deadly and has led to the rise of vaccine hesitancy with serious consequences, especially for children.
Knowledge and trust are two of the most powerful tools in fighting this Pandemic and others that will follow. Lots of information appears online, but please confirm the reliability of the sources, particularly information shared on social media. You check the weather forecast regularly, forecasts that can change quickly as new information becomes available, and it is worth your time to check in on the latest health news as well.
The World Health Organization (WHO), says that the pandemic has reached a “transition point.” They go on to say, “As such, long-term public health action is critically needed. While eliminating this virus from human and animal reservoirs is highly unlikely, mitigation of its devastating impact on morbidity and mortality is achievable and should continue to be a prioritized goal.”
Almost 10,000 coronavirus deaths were reported in December 2023, and admissions to hospitals and intensive care units surged, according to World Health Organization Director General Tedros Adhanom Ghebreyesus. “Although COVID-19 is no longer a global health emergency, the virus is still circulating, changing and killing,” said Tedros.
The risk continues to be high for the most vulnerable such as the elderly, pregnant women and people with underlying conditions (diabetes, heart disease, immunocompromised, etc.).
The risk is not shared equally as revealed by the toll it has taken on children and families in marginalized communities, warns a National Academies report focused on Black, Latino, and Native American families and low-income families. These numbers paint a disturbing reality:
—Nationwide, more than 200,000 children have lost a parent or caregiver to Covid and 65% of children who lost a parent or primary caregiver to Covid-19 are from Black, Latino, or Native American families.
—Relative maternal mortality rates increased by 33%, with the largest increases for Black and Latina women.
“Across almost every outcome, low-income and racially and ethnically minoritized children and their families have borne the brunt of the pandemic’s negative effects, and without urgent, thoughtful interventions for their health and well-being, they will continue to bear it,” the report says.
The rate of vaccine hesitancy has hampered prevention efforts, particularly in the number of people receiving at least one booster. Vaccines offer the most hopeful view of the Pandemic. Updated vaccines now provide an effective booster.
“From the start of the US vaccination campaign through the end of November 2021, COVID-19 vaccines prevented about 1.1 million deaths and 10.3 million hospitalizations in the United States,” according to estimates by the health care foundation The Commonwealth Fund. Read more about lives saved in this Vox report.
In addition, the Royal Health Society has just published a report showing the effectiveness of prevention measures during the Pandemic – data proving that they work.
World deaths from COVID have reached nearly 7 million (with experts including WHO estimating a much higher toll). Resistance to vaccines continues to challenge progress in defeating this highly contagious virus. Nearly 15 million more people may have died during the first two years of the Pandemic than was reported, WHO found.
Compounding the catastrophic death toll, globally, more than 10.5 million children have lost one or both of their parents during the coronavirus pandemic, nearly double the previous estimates, according to a research letter published in JAMA Pediatrics. READ MORE about the loss of parents.
Another alarming result of 4 years of COVID-19 can be seen in the fact that the largest sustained decline in childhood vaccinations in approximately 30 years has been recorded in official data published by WHO and UNICEF. READ MORE about this threat to children.
The United States has consistently had among the highest COVID-19 mortality rates in the world, making COVID-19 the most deadly pandemic in American history. The U.S. still reports new infections and deaths in the CDC COVID data tracker.
Health authorities address vaccine hesitancy as a significant barrier to community immunization. The wearing of masks and proper hand washing guard against infection for those who have not received the vaccine are still helpful and for those who have received the vaccine as well. Prevention and getting vaccinated are both necessary to stop COVID-19. In addition, the booster shots are another important level of protection. Being “up-to-date” on vaccination matters in the struggle with this fast changing virus.
COVID-19 has exacerbated existing ethnic inequalities in health. READ MORE in the Lancet on a new study confirming the effects of ethnic health care inequalities.
The pandemic has proven especially lethal in predominantly Black and other neighborhoods of color that face systemic inequality including lack of access to quality health care combined with a shrinking safety net for critical public services. According to the COVID Racial Data Tracker, COVID has had a deadly impact on Black, Indigenous, Latinx and other people of color with Black people dying at twice the rate of white people. In both rich and poor countries, the virus exposed and exploited every weak point in the health infrastructure. Where you live may determine whether you live or die. While some of those issues have been addressed, many of the basic causes of health inequity remain.
Global health inequity retains its deadly potential in communities of color with poor health care access as vaccine distribution lagged dangerously behind better-resourced neighbors. Vaccine hesitancy is also playing a significant role in countries and in communities in the U.S. where in the past the public health system has failed the people, leading to a historic mistrust of authorities. This lack of trust also highlights the importance of robust information and public education campaigns to promote vaccination. The COVID-19 Pandemic has brought new attention to the health equity crisis on a national and global scale and the complexity of building solutions.
COVID-19 vaccines are now part of the routine shots recommended by the CDC for kids, teens, and adults. The vaccine schedule represents the current guidelines for how to protect people against common diseases. These guidelines suggest that all people 6 months old and older should get their COVID-19 vaccines and a booster shot when they can. READ MORE about the CDC vaccination schedule.
Misinformation has hindered vaccine uptake among pregnant women. A recent poll found that one in seven adults (14%) have heard that pregnant women should not get the COVID-19 vaccine and believe it to be true, rising to nearly one in four (24%) among women who are pregnant or planning to become pregnant. READ MORE about this lingering misinformation.
COVID-19 caused a large increase in pregnancy-related deaths in the U.S. The death rate of mothers after childbirth in the U.S. is higher than many other high-income countries. Black women had a higher maternal death rate than White and Hispanic or Latina women. READ MORE about new study.
In the largest study to date, experts found that the risk of heart attack or stroke after catching COVID-19 was reduced by 41% in people who got at least two doses of a COVID-19 vaccine. This study suggests that COVID-19 vaccines may help protect against some post-COVID-19 health problems as well. READ MORE about reducing heart attack and stroke risk...
More than 40% of parents who have children 6 months to 4 years old say that they will “definitely not” get their child vaccinated against COVID-19. Scientists and medical experts have worked hard to ensure the vaccine is safe for these young kids. The COVID-19 virus, on the other hand, can be very dangerous to them. READ MORE about vaccine hesitancy affecting children.
The CDC recommends that all children 6 months through 5 years of age should receive a COVID-19 vaccine. READ MORE about the recommendation.
Kids 5 years old and older should get their COVID-19 booster shot. These boosters can better defend kids and adults from getting very sick from COVID-19. READ MORE about the booster for children.
The Department of Health and Human Services (HHS) released two reports on Long COVID. The National Research Action Plan on Long COVID details advances in current research and charts a course for future study. The Services and Supports for Longer-Term Impacts of COVID-19 report highlights resources for health care workers, and those effected by broader effects of COVID-19, including not only Long COVID but also effects on mental health and substance use, and loss of caregivers and loved ones. READ MORE about COVID long term effects.
FDA regulators authorized two antiviral medications to treat covid-19, one from Pfizer and a second from Merck. Both the Paxlovid pill from Pfizer and Merck’s Molnupiravir are considered useful tools in the fight against the coronavirus. In order to be effective, however, they must be given very early in an infection.
Paxlovid must be taken within five days after symptoms begin. READ MORE about Paxlovid.
Reports of a rebound effect from some people who have used an antiviral medication have generated a closer look at the specifics of its use, according to a story from NPR. READ MORE about the rebound effect.
Information you can trust
Americares has worked to combat the spread of disinformation and promote science and healthy behaviors that can help stem the spread of the virus. The first and most important response to a disease outbreak is to get good information. Get the facts, not fear. Understand the complexity of assembling data from a vast variety of global sources and consider using more than one source (and make sure it is a trusted source) to get a broader picture of what is happening day to day in the Pandemic.
To find answers to more of your questions about vaccines visit the WHO vaccine tracker.
COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. The JHU dashboard has ceased providing updates as of 3/10/23. Visit this resource for historical information only.
Another important daily data source can be found at CDC COVID data tracker.
The “homemade” aggregator website put together by a single enterprising programmer has become a valued, accessible data source. It continues to be updated.
The COVID Racial Data Tracker is a collaboration between the COVID Tracking Project and the Antiracist Research & Policy Center. Click here for the most complete race and ethnicity data on COVID-19 in the United States.
Researchers and Public Health Experts unite to bring clarity to key metrics guiding coronavirus response. Click here to access this new information.
Washington Post: How Do We Build Herd Immunity? Click here to learn how it happens>
A Global Crisis
The coronavirus outbreak that was first reported in December 2019 in Wuhan China exploded into a Global Pandemic – spreading like flood waters finding any and every opening to infect and kill.
According to an NPR virus tracker COVID-19, the official name of the disease caused by the virus (SARS-CoV-2) registered its first confirmed cases outside China on Jan. 20, in Japan, Thailand and South Korea. On Jan. 21, the first case in the U.S. was identified in Washington state. On Jan. 24, the first two European cases were confirmed in France. By Feb. 1, eight European nations had confirmed cases of COVID-19, and a month later that count had risen to 24 countries with at least 2,200 cases, most of them in Italy. On March 11 as Italy surpassed 10,000 cases, China, the original epicenter, reported a drop in cases of infection. March also saw a rapid spread of the virus throughout the U.S., with all 50 states reporting cases by March 17. The world took three months to reach the mark of 100,000 reported infections. The second 100,000 were added in just 12 days.
The danger to health systems is a central concern, particularly the vulnerability of health workers; thousands of health workers have been infected and many have died as health facilities became overwhelmed by the numbers of patients. Of the more that 180,000 health worker deaths that have been officially recorded, the largest number have occurred in Mexico and the U.S. (more than 3,600 in the U.S.). A lack of consistent data on health workers has hampered efforts to report on the exact toll COVID-19 is having on health workers globally and in the U.S.
Of the 192 countries/regions infected, the U.S. faced the largest outbreak. Spain and Italy in the early stages of the pandemic had a much higher death rate, reflecting an aging population – the virus is most deadly to the elderly and those with underlying health issues. Countries taking an early systematic approach to stemming the outbreak saw a leveling off and decline in reported cases, highlighting the impact of prevention and protection programs while other countries such as Brazil and Russia that had been slower to respond continued to see the infection rate accelerate. Italy and Spain shut down as the outbreak intensified and other countries closed their borders, steps that slowed the spread and offered a cautious path toward reopening. Countries such as New Zealand, Vietnam and Senegal set a standard for controlling the outbreak early by quickly establishing and following strict disease control protocols.
Impact on Vulnerable Communities
Soon after one of the first U.S. cases was reported in Washington State on January 21, another significant outbreak followed in Westchester County NY where a “containment zone” was established – a hot spot that began with one infected person. The swift decision to implement more stringent measures, including closing businesses and all but essential services, self-quarantines, masks, testing, tracing, social distancing and strong shelter-in-place recommendations in both Washington State and the Westchester communities slowed the rate of infection in those early outbreaks.
New York City soon became the major national hot zone and New York state the epicenter of the outbreak with more reported infections than any country. As the rate of infection and death toll increased in the U.S., many states including California, New York, Illinois, Ohio and Louisiana issued the “shelter-in- place” order. Communities throughout the country restricted all gatherings and encouraged people to limit social interaction and stay home to slow the progression of the pandemic. States and cities cancelled major events, conferences and other large gatherings while closing all businesses deemed non-essential and banning most events.
Decisions by some state and local leaders to keep strong measures in place to contain the virus for an extended period led to a leveling off and a significant decline in the infection and death rates in a handful of states. New York state implemented a phased reopening in regions that achieved certain benchmarks of lowered infection and fatality rates, while at the same time new hot spots emerge in many states as the pandemic continues its deadly spread. The new outbreaks led to travel restrictions into states that achieved a sharp decline in infection and death rates.
One of the most disturbing aspects of the pandemic is its disproportionate impact on predominantly Black, Indigenous and Latinx neighborhoods where social and economic inequality, a greater incidence of underlying health conditions and lack of access to health care have contributed to an alarming disparity in infection rates and deaths. The continued nationwide protests against systemic racism have given the entire issue a major role in the pandemic narrative.
Medical experts had cautioned that a premature reopening and lack of government mandates could lead to a resurgence of infections which happened in some states. The disease has been relentless, striking government leaders, top athletes and celebrities right along with health and other essential workers on the front lines of the service economy. The death of more than 3,600 health workers in the U.S., brutally underlined the critical importance of adequate supplies of protective equipment and infection prevention supplies, as well as training in their use.
What have we done?
Americares goal has always been to save lives and stop the spread of COVID-19.
Throughout the pandemic, Americares has focused our support on frontline health workers and the people they serve,
especially low-income, uninsured people in the United States and around the world.
Americares has provided access to critical supplies, support for ongoing health services and access to credible information.
The Latest COVID Initiative: COVID Treatment Quick Start
The COVID Treatment Quick Start Consortium is supporting governments to introduce and scale up access to new and effective COVID-19 oral antiviral therapies in high-risk populations. The Consortium brings together Duke University, the Clinton Health Access Initiative (CHAI), COVID Collaborative, and Americares as implementing partners, with support from the Open Society Foundations, Pfizer and the Conrad N. Hilton Foundation. Partner countries include Ghana, Kenya, Laos, Malawi, Nigeria, Rwanda, South Africa, Uganda, Zambia, and Zimbabwe.
The project kick-starts programs through a donation by Pfizer of 100,000 courses of PAXLOVID™ (nirmatrelvir/ritonavir), for which the World Health Organization (WHO) has issued a strong recommendation for use in high-risk individuals with mild to moderate COVID-19, administered within five days of symptom onset. Partners involved in the COVID Treatment Quick Start Consortium are committed to ensuring a more equitable scale-up of test-and-treat programs with antiviral medicines in low- and middle-income countries, to help address some of the challenges faced in the global scale up of vaccines.
The Shipments
The Background
Over the past three years, the COVID-19 pandemic has exposed significant global inequities in access to therapeutics, vaccines, testing, and other medical interventions that could limit the range and impact of the disease. Access to treatment has become an urgent need to tackle alongside persistently low primary vaccination and booster rates in many countries. New antiviral medicines such as PAXLOVID and molnupiravir have been available in high-income countries since late 2021 but have not been widely available in low- and middle-income countries.
Read more about the Consortium Project.
Ongoing Support
Americares has delivered protective supplies – masks, gowns, gloves and disinfectants. Our global distribution network has provided more than 18 million units of protective equipment and infection-prevention supplies for health workers worldwide. Americares has provided support to 993 partner organizations in 46 countries. The supplies helped protect health workers and patients from infection and ensure facilities could stay open and provide essential health services that low-income communities depend on. For some, Americares deliveries were their only source of items like gloves and masks; for others, the donations were critical budget relief during a time of instability.
In the U.S. alone, Americares delivered hundreds of tons of protective supplies to health facilities in 50 states, the District of Columbia, Puerto Rico, U.S. Virgin Islands and Northern Mariana Islands. Our support included 35 tons of personal protective equipment, infection-control supplies and hygiene products for Native American communities devastated by the COVID-19 pandemic. Read more about the shipments of critically needed supplies to the Hopi Tribe and Navajo Nation.
International and domestic shipments continue.
Americares global network of health care partners depends on the continuity of regular shipments of medicine and supplies from our distribution center. The most vulnerable in these communities have no other access to care.
With COVID still present in its fourth year, Americares continues to address the health care gaps that most affect disadvantaged communities. This has included continuity of quality health services and access to essential medicine and supplies. This work becomes more complex and even more important as we respond to manmade and climate change related disasters such as the War in Ukraine and extreme weather events in the U.S. and around the world.
Watch the video of our Distribution Center in action!
Americares has worked on the frontlines of the COVID-19 response in the US where we have been needed. For example, In response to an urgent request from FEMA, Americares mobilized three medical professionals to support Citizen Potawatomi Nation (CPN) Health Services’ COVID-19 response. CPN Health Services is located in Oklahoma and services patients who are either Native American, have a Certificate of Degree of Indian Blood (CBID), or are a CPN service provider. Americares three medical professionals helped to administer COVID-19 vaccinations, COVID-19 booster shots to eligible populations, COVID-19 testing, and flu vaccinations. The two health clinics operated by CPN Health Services (East and West) provide health care services, including COVID-19 vaccination and testing, to Native populations including but not limited to Potawatomi, Cherokee Nation, Chickasaw Nation and the Kickapoo Tribe of Oklahoma.
Americares response team of medical professionals provided daily assistance, allowing tribal leadership and FEMA to identify a longer term staffing plan.
Americares provided primary care services at its clinics in Connecticut, Colombia, El Salvador and its mobile health centers in India throughout the pandemic. In the Americares clinics health workers helped to identify suspected COVID-19 infections and referred patients for testing and related treatment. In our El Salvador clinic location, we provided rapid antigen testing.
The COVID-19 pandemic increased the barriers to care that low-income uninsured people experience every day. With clinics closed or on reduced hours early in the Pandemic, patients who already struggled to access care risked complications and even death from untreated chronic diseases and other health problems. Americares COVID-19 response helped ensure that patients at both Americares-own clinics and those of our partners had safe access to health services.
In Colombia, India and the United States, Americares clinics quickly pivoted from in-person appointments to telehealth services in response to government restrictions, opening when rules allowed. Americares clinics in Colombia, and El Salvador closed temporarily and then were able to restore in-person care, adhering to strict safety protocols for staff and patients. In response to the devastating COVID-19 surge in India, Americares India, which normally operated seven mobile health centers in the slum communities of Mumbai, faced an extraordinary surge in the Pandemic across the country in 2021 and expanded its support for hospitals overwhelmed by the surge. Americares India team supported 242 dedicated COVID-19 treatment facilities in 32 states and union territories with life-saving medical equipment and desperately needed personal protective equipment. Learn more about the Americares India response.
Overall, more than one million patient visits, including telehealth, have been managed in Colombia, El Salvador, India, Peru and the U.S. (Connecticut) since the start of the Pandemic.
Our top concern has been the capacity of under-resourced health centers to respond to the pandemic. Americares has trained health workers in infection prevention and control, disaster preparedness and mental health and psychosocial support. Americares hosted 718 training sessions attended by nearly 46,000 participants. Americares has trained more than 26,000 participants in psychological first aid and coping skills to handle fear, stress and anxiety.
To reinforce vaccine confidence among health care personnel, and in turn the patients and communities they serve, Americares is supporting and will continue to promote a range of efforts to build COVID-19 vaccine confidence among our health center networks and the broader public. Vaccine confidence training and education sessions continue to be provided to health workers and key stakeholders across Africa and the Middle East, Latin America and the Caribbean, and the United States. The CDC Reinforcing COVID-19 Vaccine Confidence project was launched to build and reinforce COVID-19 vaccine confidence among healthcare personnel in the safety net sector in the U.S. and in turn the patients they serve. In addition, the “Wear A Mask” campaign generated more than 2 million engagements on Social Media and 42,000 streams of the Wear A Mask song.
Other ongoing work includes:
— Grant support to partners who have implemented COVID response, prevention or misinformation work, such as Birat Medical Trust in Nepal for purchase of PPE, hygiene supplies and surge support lab personnel and support to Misean Cara supporting multiple partners in Africa on various COVID projects.
— Support for vaccination efforts: COVID vaccination in the Philippines; COVID vaccinate-with-confidence work in the US including ECHO sessions for free and charitable clinic staff; COVID vaccination awareness/uptake work in Tanzania.
Without running water, it’s nearly impossible for staff and patients to follow safety protocols so, in 10 countries, Americares collaborated with local health partners to improve water infrastructure. We have provided communities with hundreds of water infrastructure improvements, including hand-washing and hand-sanitizing stations. In every location where Americares has provided hand-washing stations, we have also done community education and outreach on hygiene. We continue to support WASH interventions with emphasis on health workers providing quality of care.
In Peru, Americares provided surge medical support in Peru from June 2020 through March 2021 to support health facilities overwhelmed by the pandemic. Americares relief workers also provided rapid COVID-19 testing in partnership with VIDA Peru, at mobile clinics in communities with high rates of COVID-19 in Lambayeque, Lima and Piura and reached over 200,000 people with COVID-19 health education throughout the duration of the project. Additionally, Americares psychologists provided mental health consultations.
Americares knows from a long history of disaster response that maintaining primary care services during crisis is critical to saving lives and restoring health.
Watch the video with Nurse Practitioner Mary Beth Fessler on treating patients at Americares Free Clinics during the pandemic.
Americares thanks you
Thank you to the following institutional partners for their support of Americares COVID-19 response:
Americares Emergency Response Partners
What can you do?
We work with a dedicated and experienced staff, a global network of health care partners, corporate partners and donors. The success of this unprecedented fight against a global pandemic relied on the coordinated efforts of federal, state and local authorities, global and local non-profits, community action and most of all you.
You have the greatest power to change the course of this global disaster: Get the vaccine (and a booster). It will help to keep you, your family and your community safe. Even with mandates ended, the pandemic is still with us. Be cautious and stay healthy.
And you can do one other important thing: Fight the “infodemic” by getting the facts, sharing the facts and following the science.
Prevention and protection come down to individual actions to keep everyone safer. Those actions have been the key to controlling the pandemic. Remember to be vigilant. In spite of the progress, we still have a long way to go before most people around the world receive the required doses. Treatments for COVID have been approved but none offer a cure. The virus is not going away. In fact, it has returned in waves along with new variants of the virus. It remains highly contagious, and it seizes any opportunity. Don’t give it one. Get the vaccine and booster.
Download a useful guide on proper hand washing and other preventive tips right now. It might be a lifesaver.
Haga clic aquí por un guía de lavado de manos—podría salvar su vida. Hag clic aquí.
“Because public health measures are really only as good as the public using them and implementing them, or at least the majority. I’d say that especially with this outbreak, this is something that we’re all in on together. It’s not just about my risk or my family’s risk, you know, and that kind of individual piece, this is something where we’re working as a community.” Dr. Julie Varughese
“Because public health measures are really only as good as the public using them and implementing them, or at least the majority. I’d say that especially with this outbreak, this is something that we’re all in on together. It’s not just about my risk or my family’s risk, you know, and that kind of individual piece, this is something where we’re working as a community.”
A third of Americans report signs of clinical anxiety or depression in a US Census Bureau poll, documenting COVID-19’s alarming impact on mental health.
Watch mental health experts discuss and share mental health issues that arise during a crisis along with tips from Mental Health professional Lisa LaDue about relieving stress in difficult times. vimeo.com/showcase/mentalhealthindisasters
Americares has extensive experience with outbreaks including in response to Ebola in West Africa and DRC, Zika in Latin America and the Caribbean as well as recent outbreaks of Measles and Dengue so we are ready to respond as the situation evolves. The organization has professional relief workers ready to respond to disasters at a moment’s notice and stocks emergency medicine and supplies in warehouses in the United States, Europe and India that can be delivered quickly in times of crisis.