Hostname: page-component-857557d7f7-v48vw Total loading time: 0 Render date: 2025-11-21T01:18:49.278Z Has data issue: false hasContentIssue false
  • English
  • Français

Advocating for Health in a Politically Complex World: Integrating Situational Awareness and Disaster Mindset into Multilevel Advocacy Resilience Framework (MARF)

Published online by Cambridge University Press:  13 November 2025

Amir Khorram-Manesh Open the ORCID record for Amir Khorram-Manesh [Opens in a new window]
Amir Khorram-Manesh*
Affiliation:
Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg , Gothenburg, Sweden Center for Disaster Medicine, University of Gothenburg , Gothenburg, Sweden Gothenburg Emergency Medicine Research Group, Sahlgrenska University Hospital, Gothenburg, Sweden
*
Corresponding author: Amir Khorram-Manesh; Email: Amir.khorram-manesh@surgery.gu.se
Rights & Permissions [Opens in a new window]

Abstract

Disasters and emergencies, from natural hazards to complex crises, demand a fundamental shift in traditional management paradigms. At all levels of disaster and emergency management, from frontline responders to high-level policymakers, 2 integrated concepts—situational awareness and a disaster mindset—are critical for effective response and resilience. Situational awareness is not merely the collection of data; it’s the dynamic and continuous process of perceiving, comprehending, and projecting a holistic understanding of the operational environment, including evolving threats, available resources, and stakeholder dynamics. When fused with a disaster mindset—a psychological and strategic posture characterized by proactive anticipation, radical adaptability, and decisive action under pressure—it creates a powerful framework for navigating uncertainty. This paper, presented as the Frederick M. (“Skip”) Burkle lecture, proposes a new, integrated framework that systematically applies these concepts to enhance decision-making and operational effectiveness across all managerial tiers, enabling a transition from a reactive to a proactive and resilient posture in the face of escalating global complexities.

Keywords

Disaster mindsetframeworkhealthmultilevelresiliencesituational awareness

Information

Type
Invited Review
Information
Disaster Medicine and Public Health Preparedness , Volume 19 , 2025 , e315
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2025. Published by Cambridge University Press on behalf of Society for Disaster Medicine and Public Health, Inc

Introduction

In an era defined by intersecting crises—from global pandemics and climate-fueled disasters to protracted conflicts and forced migrations—the mission to protect and promote public health has never been more critical, nor more fraught with complexity.Reference Burkle, Koenig and Schultz 1 Advocating for health is no longer confined to the sterile environments of clinics and laboratories; it is a battle fought on the contentious ground of politics, economics, and international relations. Success in this challenging arena demands more than just medical expertise or sound policy. It requires a fundamental shift in perspective, anchored by 2 critical concepts: situational awareness (SA) and a disaster mindset (DMS).Reference Khorram-Manesh, Taskiran Eskici and Gray 2

SA is the essential ability to perceive and understand the dynamic elements of a complex environment, and to project their future status.Reference Endsley, Salvendy and Karwowski 3 In the context of a public health emergency, it means moving beyond a simple count of cases or a map of affected areas. It is the holistic comprehension of the intricate web of factors at play: the capacity and resilience of the local health care system, the flow of accurate and false information, the political will (or lack thereof) of governments, the logistical bottlenecks in supply chains, and the sociocultural fabric of the affected communities.Reference Khorram-Manesh, Taskiran Eskici and Gray 2 , Reference Dixon, Grannis and McAndrews 4

For a frontline health care worker, it’s recognizing that a lack of clean water will imminently lead to a secondary disease outbreak. For a national health minister, it’s understanding how electoral politics might impede the implementation of a necessary lockdown. Lacking this comprehensive view, as demonstrated during the COVID-19 pandemic, is akin to navigating a minefield blindfolded; decisions are made in a vacuum, resources are misallocated, and preventable tragedies unfold.Reference Harper, Mustafee and Pitt 5 , Reference Montori, Ruissen and Hargraves 6

Complementing this outward-looking perception is the inward-looking preparedness of a DMS. This is the proactive, rather than reactive, approach to threats. It is the ingrained understanding that systems will fail, communication will break down, and the unthinkable can and will happen.Reference Khorram-Manesh, Taskiran Eskici and Gray 2 , Reference Su, McDonnell and Ahmad 7 A DMS rejects complacency and “normalcy bias.” At the individual level, it fosters resilience, adaptability, and the capacity for improvisation when initial plans crumble. DMS differs from disaster readiness and disaster growth. Disaster readiness refers to the tangible, practical actions taken to prepare for a disaster, while disaster growth indicates the experience gained after a disastrous event. DMS refers to the mental ability to make critical decisions during dynamic emergencies based on the available, and sometimes insufficient information (Table 1).Reference Su, McDonnell and Ahmad 7 –Reference Southwick, Satodiya and Pietrzak 9

Table 1. Shows the differences between DMS, disaster readiness, and disaster growth Reference Khorram-Manesh, Taskiran Eskici and Gray2,Reference Su, McDonnell and Ahmad7-Reference Southwick, Satodiya and Pietrzak9

At the institutional and governmental levels, it translates into robust contingency planning, strategic stockpiling of essential goods, regular stress-testing of emergency protocols, and the empowerment of local decision-makers. It is the crucial shift from asking “if” a crisis will occur to operating on the assumption of “when,” and building the muscle memory to act decisively and effectively amidst the chaos.Reference Coccia 10 The importance of these twin concepts permeates every level of emergency management, influenced by both their facilitators and constrainers. From the local community organizer mobilizing volunteers to the international diplomat negotiating humanitarian access, the principles remain the same. Effective advocacy and action in today’s politically charged landscape are impossible without them.

This introduction serves as a gateway to exploring how we can cultivate this awareness and mindset, enabling us to navigate the intricate political and medical realities and champion the fundamental human right to health, even when faced with the most daunting of challenges.

Situational Awareness, Disaster Mindset, and Managerial Levels

Building on the foundational concepts of SA and a DMS, their application and the factors that influence them differ significantly across the hierarchical levels of disaster and public health management (Figure 1). Below is a detailed elaboration for the Strategic, Tactical, and Operational managerial levels.

Figure 1. The various factors impacting different managerial levels in disaster and public health emergencies (by Khorram-Manesh A, an AI-image produced by Microsoft Copilot).

The operational level: the “Doing”

This is the front line of any disaster, where responders have direct contact with the affected population and the immediate hazards. At this level, the need for SA is immediate, tangible, and highly dynamic. It is the process of rapidly understanding the scene to make life-saving decisions in seconds and minutes. For a paramedic arriving at a multi-car pile-up, SA encompasses questions like: How many victims are there? What are their immediate injuries (triage)? Is there a fire or fuel leak (hazards)? Is the scene safe from further collisions? For a public health worker in a village, it’s: Does this family have clean water? Are they showing symptoms of cholera? Who else have they been in contact with? The focus is on gathering just enough specific, actionable information to perform the next critical task. It is sensory—what you can see, hear, and smell—and directly informs hands-on intervention.Reference Qureshi and Ciottone 11 , Reference Ahmad, Maynard and Desouza 12

There are several factors that could impact operational awareness, such as:

  • • Environmental factors. Visibility (smoke, darkness, weather), noise levels, physical accessibility of the site, and ongoing hazards (e.g., unstable structures, active shooters).

  • • Resource availability. The number of responders versus the number of victims, availability of personal protective equipment (PPE), functionality of medical and communication equipment.

  • • Human factors. The individual responder’s level of physical and mental fatigue, stress, training, and experience.

DMS at the operational level is an ingrained discipline that allows for effective action amidst chaos. It is about adherence to protocol while being prepared to improvise. It’s the firefighter who, upon seeing a compromised structure, immediately establishes a collapse zone without being told. It’s the triage officer who sticks to the objective START protocol, resisting the emotional pull to treat a less critical but more vocal victim first. It’s the nurse who, when the power fails, has already mentally rehearsed how to manage ventilated patients manually.Reference Khorram-Manesh, Taskiran Eskici and Gray 2 , Reference Su, McDonnell and Ahmad 7 , Reference Hugelius and Harada 13 This mindset is built through relentless, realistic training and instills the resilience to remain effective when faced with overwhelming sights and sounds. There are also several factors that could impact the mindset in this level, such as:

  • • Training and protocols. The quality, realism, and repetition of hands-on training exercises; the clarity and simplicity of standard operating procedures (SOPs) and triage systems.

  • • Team cohesion. Trust in teammates and leadership, clear communication, and a shared understanding of roles and responsibilities.

  • • Personal resilience. An individual’s psychological fortitude, physical preparedness, and ability to manage stress and personal safety to remain an effective asset.

The tactical level: the “How”

This is the coordination hub, where information from multiple operational units is synthesized to manage the overall response within a specific region or sector. This level translates strategic goals into concrete actions. Tactical assessment moves from individual victims to managing populations and resources. The goal is to create a “Common Operating Picture” (COP) that allows for the efficient deployment of operational assets.Reference Ahmad, Maynard and Desouza 12 , Reference Apostolakis, Dimitriou and Margetis 14

The incident commander in a regional Emergency Operations Center (EOC) is not assessing a single patient but asking: Which hospitals are full? Where can we direct incoming ambulances? What is the burn rate of our PPE stockpile? Are the transportation routes for logistics convoys still open? This involves aggregating data from dozens of operational units to identify emerging patterns, predict needs for the next 12-72 hours, and allocate resources where they will have the greatest impact.Reference Khorram-Manesh, Hedelin and Örtenwall 15 The following factors influence SA during the tactical assessment:

  • • Information systems. Reliability of communication networks (radio, satellite), functionality of data management platforms, geographical information system (GIS) mapping capabilities, and real-time resource tracking systems.

  • • Inter-agency coordination. The presence and effectiveness of liaison officers from different agencies (fire, police, public health, military), which prevents silos of information.

  • • Data quality. The accuracy, timeliness, and completeness of reports coming up from the operational level.

The tactical DMS is about flexibility, anticipation, and redundancy. It accepts that the initial plan is a starting point, not a rigid script.Reference Hannah, Jennings and Nobel 16 It’s the Health Director who, anticipating that hospitals will be overwhelmed, proactively works with engineers to convert a local convention center into a field hospital. It is the logistics chief who, knowing a supply route is vulnerable to flooding, pre-positions caches of material along alternative routes. This mindset involves constantly asking “What’s next?” and “What if?” It’s about empowering operational leaders with a clear “commander’s intent” so they can adapt to changing conditions on the ground without waiting for new orders.Reference Crundall, Van Loon, Baguley and Kroll 17 , Reference Phattharapornjaroen, Carlström and Khorram-Manesh 18 This level could also be affected by the following factors:

  • • Planning and agreements. The existence of well-exercised contingency plans and pre-negotiated mutual aid agreements between different jurisdictions and agencies.

  • • Delegation of authority. Clear policies that allow tactical commanders to make significant financial and resource decisions without seeking higher approval, speeding up the response.

  • • Resourcefulness. The ability to find and adapt non-traditional resources (e.g., using beverage trucks for water transport, recruiting veterinary clinics for medical support).

The strategic level: the “Why”

This is the highest level of leadership, focusing on national or international policy, long-term priorities, and the overarching political and economic implications of the crisis. Strategic assessment has the broadest scope in both time and space. It’s about understanding the total, long-term impact of the crisis on the nation and its place in the world.Reference Wong, Gerras and Kidd 19 A Prime Minister or a WHO Director-General is not focused on the location of a single ambulance, but on the crisis’s cascading effects. They assess: What is the projected economic impact over the next year? How will this affect diplomatic relations or international trade? What public messaging is needed to maintain trust and social cohesion? How do we allocate the national budget between immediate relief and long-term recovery? This involves analyzing intelligence reports, epidemiological and economic models, and global trends to set national priorities and the overall objective of the response.Reference Ruiu, Wardman and Löfstedt 20 The strategic level could be influenced by the following factors:

  • • Geopolitical factors. Relationships with neighboring countries, international treaties, the presence of non-state actors, and global supply chain vulnerabilities.

  • • Economic and social factors. The state of the national economy, public sentiment and media narratives, existing social inequalities that create specific vulnerabilities, and the overall trust in government.

  • • Scientific and intelligence input. The quality of scientific modeling (e.g., pandemic spread, hurricane tracks), intelligence briefings, and expert advice from bodies like the Scientific Advisory Group for Emergencies.

At this level, a DMS is about political courage and foresight. It involves making difficult, high-stakes decisions based on incomplete and uncertain information to avert a potential catastrophe.Reference Cortes and Herrmann 21 It’s the political leadership that makes the unpopular decision to close borders or issue stay-at-home orders early in a pandemic, knowing the economic cost but acting on scientific projections of a far worse outcome if they delay. It is the legislature that allocates significant funding for national resilience (e.g., seismic retrofitting of infrastructure, creating a strategic pandemic-reagent stockpile) during times of peace and prosperity. This mindset rejects political expediency in favor of national security and long-term public welfare, championing preparedness as a continuous, non-negotiable state function.Reference Burkle, Bradt and Ryan 22 Nevertheless, this level may also be influenced by several factors:

  • • Political will and system. The electoral cycle, political ideology, public opinion, and the ability of the political system to act decisively.

  • • Legal framework. The existence of pre-authorized emergency powers, public health laws, and clear legal frameworks for declaring a state of emergency.

  • • Leadership and history. The personal risk tolerance and experience of the leaders, and the nation’s own history with past disasters, which can either foster complacency or a culture of preparedness.

As crises and emergencies expand and the severity of situations becomes more prominent, the need for SA and a DMS increases simultaneously and at the same pace, even though the demand on a DMS might be more to enable critical decision-making based on available information.Reference Khorram-Manesh, Taskiran Eskici and Gray 2 These elements together form the foundation of comprehensive emergency management, demonstrating how on-the-ground tactics and systemic influences are interconnected. Achieving collaboration, i.e. a unified approach to emergency management, coordination, and cooperation, is essential and hinges on the establishment of a robust communication system. In this context, current technological advancements and the ongoing discourse surrounding their application in disaster and emergency management play a critical role. These technologies are vital for enhancing SA and DMS, ensuring the seamless flow of information, strengthening communication, and ultimately enabling the timely implementation of COPs.Reference Bjerge, Clark and Fisker 23

The importance of these non-medical skills (i.e., SA and DMS) can be illustrated by using 2 critical processes during an emergency: 1) Triage and resource allocation, and 2) Political impacts on decision-making.

Case Studies on the Impacts of Triage and Politics on SA and a DMS

Triage

In the chaotic aftermath of a mass casualty incident (MCI) or disaster, the single most critical medical challenge is allocating insufficient resources to an overwhelming number of victims. This is the grim reality of triage, a process that moves beyond the traditional medical ethic of “first come, first served” to the utilitarian principle of doing the greatest good for the greatest number.Reference Khorram-Manesh, Gray and Goniewicz 24 The work of several scholars, such as F.M. Burkle, in disaster medicine, provides a crucial framework for understanding modern triage. Their publications consistently underscore that effective triage is not merely a clinical sorting tool but a dynamic process fundamentally reliant on advanced SA and a deeply ingrained DMS.Reference Peta, Day and Lugari 25 –Reference Khorram-Manesh 27

Disaster triage differs fundamentally from daily emergency medicine. In a hospital’s emergency room, every patient receives comprehensive care. In a disaster, resources—personnel, equipment, time, and transport—are immediately outstripped by demand. Triage becomes the essential, brutal calculus for prioritizing care for the injured.Reference Bazyar, Farrokhi and Salari 26 , Reference Khorram-Manesh 27 This involves sorting casualties into categories, commonly labeled as, 1) IMMEDIATE (Red): Life-threatening injuries that are survivable with minimal intervention, 2) DELAYED (Yellow): Significant injuries requiring medical care, but which can wait without threat to life or limb, 3) MINOR (Green): “Walking wounded,” who need minimal or no professional medical care, and 4) EXPECTANT/DECEASED (Blue/Black): Victims who are either deceased or have such catastrophic injuries that they are unlikely to survive given the available resources.Reference Bazyar, Farrokhi and Salari 26 , Reference Rådestad, Montán and Rüter 28 The final category (Expectant/Deceased) is the most difficult ethically and operationally, representing the starkest departure from nondisaster medicine. It is a decision that can only be made and justified within the context of a true mass casualty event.Reference Rådestad, Montán and Rüter 28 , Reference Varshney, Mallows and Hamd 29

Scholars with extensive field experience in conflicts and humanitarian crises have been a foundational voice in defining the scope of disaster medicine. Burkle, for instance, argues that triage cannot be seen as a single, static event performed at the point of injury. Instead, it is a continuous, iterative process that reoccurs at every stage of the patient’s journey—from the field to the casualty collection point, to the field hospital, and during evacuation. He stresses that triage decisions are inherently fluid and must change as the tactical situation evolves. For Burkle, the DMS is paramount. This mindset forces planners and responders to accept the abnormal conditions of a disaster as the new reality. It means accepting that perfect care for everyone is impossible and that the goal has shifted to saving the maximum number of lives.Reference Burkle 30 , Reference Burkle 31 Without this mental shift, responders can become paralyzed by the ethical weight of their decisions or misapply daily emergency standards, leading to a collapse of the triage system.Reference Cuthbertson and Penney 32

Other researchers have built upon this foundation with extensive research on the practical application of triage systems, disaster preparedness, and the cognitive challenges faced by responders. These publications frequently dissect the components of an effective response, focusing on systems and education by highlighting the critical importance of SA for effective triage, emphasizing that the person performing triage must assess more than just the patient’s vital signs.Reference Khorram-Manesh, Nordling and Carlström 33 –Reference Khorram-Manesh, Carlström and Burkle 35 Their assessment must include awareness of the hazards, i.e. is the threat ongoing (e.g., active shooter, chemical leak)? Are resources available, i.e. how many ambulances are en route? What is the capacity of the nearest hospital? How does the environment look like, i.e. are we in a confined space? Is the weather a factor? Finally, how is the system working, i.e. what is the agreed-upon triage protocol? How is information being relayed to tactical command?

This champions the need for education and training that goes beyond simple algorithms, advocating for exercises that build this holistic SA, arguing that even the best triage algorithm will fail if the responder is not aware of the broader context. A red-tagged patient is meaningless if there is no ambulance available for transport for several hours.Reference Khorram-Manesh 27 This awareness allows for crucial adaptations, such as establishing an “immediate care” area on-site when transport is delayed, a direct application of tactical medicine principles to civilian MCI management, or using local layperson as immediate responder to act before the first responders arrive.Reference Khorram-Manesh, Plegas and Högstedt 36

The translational triage tool (TTT) proposed by Khorram-Manesh, Burkle et al. (Figure 2) is not a new, standalone triage system, but rather an algorithm designed to unify existing prehospital triage methods into a single, compatible framework. Its algorithm focuses on key, universally understood assessment steps like ambulation, breathing, respiratory rate, radial pulse presence, and ability to follow commands. By identifying these common denominators across various systems (like START or Sieve), the TTT aims to provide a simplified, rapid assessment that can be understood and applied by different agencies, facilitating seamless integration from the incident scene to hospital care and improving overall efficiency in mass casualty incidents. While it may result in a higher rate of over-triage, it aims to eliminate under-triage, thereby preventing avoidable deaths.Reference Khorram-Manesh, Nordling and Carlström 33 –Reference Khorram-Manesh, Carlström and Burkle 35

Figure 2. Translational triage tool (by Khorram-Manesh et al.).Reference Burkle 30 –Reference Cuthbertson and Penney 32

In triage, SA and a DMS are 2 sides of the same coin, both essential for a successful response. Reference Khorram-Manesh 27 A DMS provides the psychological and ethical framework for prioritizing care in an MCI, while SA offers the real-time data needed to apply these principles effectively.Reference Vassallo, Moran, Cowburn and Smith 37 , Reference Vassallo, Cowburn and Park 38 For example, the DMS accepts that difficult choices must be made for the greater good, and SA helps the responder answer questions like, “Given the resources available, is this patient a priority right now?” Together, these 2 elements transform triage from a simple medical algorithm into the cornerstone of an effective MCI response, allowing responders to adapt and save the most lives possible.Reference Khorram-Manesh 27 , Reference Burkle 30 , Reference Burkle 31 , Reference Khorram-Manesh, Nordling and Carlström 33 –Reference Vassallo, Cowburn and Park 38

Besides physically injured people, health care may need to manage “worried well” individuals during emergencies. This can be done by using clear communication, redirecting care, and offering emotional support. The key is to provide consistent public messaging through multiple channels, clearly advising who should and should not come to the hospital. To prevent overcrowding, they can set up separate, off-site clinics or triage areas specifically for people with anxiety, staffed by mental health professionals. Crucially, all hospital personnel should be trained in providing basic psychological support and empathy to acknowledge patients’ fears, which can de-escalate the situation and ensure that critical resources remain available for those who are seriously injured.Reference Gray, Dineen and Sidaway-Lee 39

The Impact of Politics

The intricate web of politics casts a long and often decisive shadow over the landscape of MCIs and disasters. Politics, governance, and leadership are not secondary to disaster management; they are central to it. Disaster medicine literature consistently demonstrates that political choices and leadership styles significantly impact a response’s effectiveness and the survival of those affected. Experts frequently point to the need for both SA and a DMS to successfully navigate these complex environments.Reference Guggenheim 40 –Reference Burkle and Hanfling 45

Leadership’s impact: from humility to narcissism

Effective leadership is essential, and traditional disaster management models favor leaders who are humble, adaptable, and collaborative. These qualities are crucial for fostering SA and guiding a unified response. However, although they may have both positive and negative impacts on a process, narcissistic traits can fundamentally compromise this process. Leaders with an inflated sense of self-importance, entitlement, and a need for admiration often prioritize their own image over the collective good. This leads to several key failuresReference Burkle and Hanfling 45 , Reference Khorram-Manesh and Burkle 46 , Reference Khorram-Manesh, Goniewicz and Burkle 47:

Political hindrances to effective response

Political factors often create major obstacles. Political denial and systemic inertia, for instance, can critically undermine preparedness and response.Reference Birchall and Kehler 42 Scholars like F.M. “Skip” Burkle Jr. echo this, arguing that even when scientific expertise and resources are available, their use is often hampered by political agendas and partisan priorities. He emphasizes that during a crisis, political rhetoric and fearmongering frequently override reasoned expertise, leading to delayed actions, misallocated resources, and an erosion of public trust.Reference Burkle 44 , Reference Burkle and Hanfling 45 Goniewicz et al. highlight how the combination of climate change and political inaction poses a formidable threat to global public health. The crisis in Ukraine is a powerful example of how authoritarian leadership and geopolitical maneuvering can directly cause a public health catastrophe, overwhelming health care systems and worsening human suffering.Reference Goniewicz, Burkle and Khorram-Manesh 43

The role of SA and DMS

To counteract these political influences, experts advocate for cultivating SA and a DMS. SA is more than just knowing the physical environment. It’s the ability to grasp the complex interplay of political, social, and logistical factors and to anticipate their future impact. A high degree of SA allows disaster managers to foresee political hurdles, identify key stakeholders, and adapt their strategies to a politically charged environment. DMS is a proactive, anticipatory approach to crisis management. It involves continuous preparedness, creative problem-solving, and resilience in settings where traditional command structures might be compromised by political motives. Together, SA and a DMS empower disaster professionals to navigate political complexities and improve response outcomes.Reference Khorram-Manesh, Taskiran Eskici and Gray 2 , Reference Su, McDonnell and Ahmad 7 , Reference Goniewicz, Burkle and Khorram-Manesh 43

The recent work in this field serves as a critical reminder that MCIs and disasters are not just logistical or medical challenges; they are deeply political events. The success of any response is contingent on the ability of those involved to understand and navigate the complex political terrain. By fostering SA and a pervasive DMS, it becomes possible to mitigate the negative impacts of politics and ultimately save lives.Reference Burkle, Khorram-Manesh and Goniewicz 48 To standardize and navigate health care in political complexities, a Multilevel Advocacy Resilience Theoretical Framework (MARF) is needed.

Introducing the multilevel advocacy resilience framework (MARF) in political complexity

Traditional health advocacy models often assume a predictable environment. However, the modern, politically charged landscape requires a new approach. MARF represents a novel framework that applies principles from fields like emergency management and military strategy to health advocacy.

MARF synthesizes established concepts to create a more dynamic and adaptable approach. Encompassing the core ideas of SA and a DMS, applied at every level of an organization to create a cohesive and resilient response to complex challenges, it draws from Endsley’s three-level model, in which SA is a dynamic, ongoing process of collecting and interpreting information to create a comprehensive mental model of the environment through perception, comprehension and projection of the working environment.Reference Endsley and Salas 49

In the context of health advocacy, SA means understanding the political landscape—who is in power, their motivations, and how information is being manipulated. DMS provides the strategic and psychological tools to act effectively. It is a proactive, forward-looking perspective that allows an organization to pivot its strategies in response to unexpected political shifts or setbacks. The concept is a conceptual twin to the proactive, resilience-building approaches seen in disaster management frameworks. MARF’s focus on a DMS is akin to modern disaster management frameworks, such as the UN Sendai Framework for Disaster Risk Reduction.Reference Pearson and Pelling 50 These models emphasize anticipating risks and strengthening capacities rather than simply reacting to events.

MARF integrates different aspects of crisis management, such as information sharing, decision-making, and resource allocation. It aligns with the concept of “shared situational awareness” (SSA), which highlights the need for a common operating picture among different stakeholders.Reference Pollack, Mishra and Apodaca 51 Finally, MARF naturally fits into the “Whole of Society” approach by highlighting the critical role of non-governmental organizations in navigating crises. This concept, prominent in recent resilience frameworks like the UK Government’s Resilience Framework, 52 and the flexible surge capacityReference Phattharapornjaroen, Carlström and Khorram-Manesh 18 emphasizes that effective crisis management requires the active participation of all societal actors, including civil society, the private sector, and academia (Table 2).

Table 2. Summarizing MARF by detailing the focus, application of SA and a DMS, and specific operational tools for each of the three organizational levels

MARF demonstrates how SA and a DMS are applied differently at three distinct organizational levels to create a unified, resilient response. While MARF is a strong conceptual model, its true value comes from making it operational. This requires implementing specific tools, processes, metrics, and training at each organizational level (Table 2). MARF is a unique and valuable contribution to academic literature because it explicitly integrates a DMS with SA and applies these concepts specifically to political health advocacy. While many existing frameworks focus on logistics (e.g. a fire’s location or the number of casualties), MARF adapts these principles to the medical and political context, addressing questions of power, motivation, and information manipulation. By combining well-established ideas in a novel way, this framework provides a practical, living system for organizations to navigate complex and uncertain environments. Nevertheless, it must be tested and updated before being fully implemented (Figure 3).

Figure 3. An effective disaster and emergency response system comprises several key components. At its core is situational assessment (SA), the process of gathering and analyzing essential information, including critical political, social, and cultural factors. This assessment supports informed medical decision-making and enhances resource allocation through the concept of flexible surge capacity. Additionally, the use of translational triage tools helps prevent unnecessary fatalities caused by incompatible triage systems, especially within a multiagency collaborative framework.

Challenges in Achieving SA and DMS

Effective disaster management requires more than just reacting to events—it demands proactive preparation (Table 3).

Table 3. A brief explanation of the challenge and its impact on emergency response efforts

By anticipating and mentally preparing for the challenges to SA and a DMS, we can counteract these barriers through proper education, robust protocol design, and regular exercises, necessitating a theoretical framework to improve our ability to handle future crises irrespective of etiology.

Conclusion

In conclusion, SA and a DMS are critical for effective health advocacy in a complex political environment. While traditional models focus on a predictable setting, the MARF adapts concepts from emergency management and military strategy to create a more dynamic approach to disaster and emergency management.

Data availability statement

All data are available online.

Acknowledgment

This work was presented as the “Skip” Burkle Lecture during the second Disaster and Emergency Medicine Conference in Bangkok, arranged by the Chulabhorn Royal Academy and the Society for Disaster Medicine and Public Health. The paper is dedicated to Frederick M. “Skip” Burkle for his extensive commitment to improving global health equity and access.

Funding statement

None.

Competing interests

The author declares no conflict of interests.

Ethical standard

Not applicable.

References

Burkle, FM Jr. Complex public health emergencies. In: Koenig, KL, Schultz, CH, eds. Disaster Medicine: Comprehensive Principles and Practices. Cambridge University Press; 2016:782.Google Scholar
Khorram-Manesh, A, Taskiran Eskici, G, Gray, L. Enhancing global disaster preparedness: A scoping review of the current integration of situational awareness and disaster mindset in healthcare education. AIMS Public Health. 2025;12(3):735–766. doi:10.3934/publichealth.2025038CrossRefGoogle ScholarPubMed
Endsley, MR. Situation awareness. In: Salvendy, G, Karwowski, W, eds. Handbook of Human Factors and Ergonomics. Wiley Online Library; 2021:434–455.10.1002/9781119636113.ch17CrossRefGoogle Scholar
Dixon, BE, Grannis, SJ, McAndrews, C, et al. Leveraging data visualization and a statewide health information exchange to support COVID-19 surveillance and response: application of public health informatics. J Am Med Inform Assoc. 2021;28(7):1363–1373.10.1093/jamia/ocab004CrossRefGoogle Scholar
Harper, A, Mustafee, N, Pitt, M. Increasing situation awareness in healthcare through real-time simulation. J Oper Res Soc. 2023;74(11):2339–2349.10.1080/01605682.2022.2147030CrossRefGoogle Scholar
Montori, VM, Ruissen, MM, Hargraves, IG, et al. Shared decision-making as a method of care. BMJ Evid Based Med. 2023;28(4):213–217.10.1136/bmjebm-2022-112068CrossRefGoogle ScholarPubMed
Su, Z, McDonnell, D, Ahmad, J. The need for a disaster readiness mindset: A key lesson from the coronavirus disease 2019 (COVID-19) pandemic. Infect Control Hosp Epidemiol. 2022;43(4):538–539.CrossRefGoogle ScholarPubMed
Gowan, ME, Sloan, JA, Kirk, RC. Prepared for what? Addressing the disaster readiness gap beyond preparedness for survival. BMC Public Health. 2015;15(1):1139.10.1186/s12889-015-2440-8CrossRefGoogle ScholarPubMed
Southwick, SM, Satodiya, R, Pietrzak, RH. Disaster mental health and positive psychology: An afterward to the special issue. J Clin Psychol. 2016;72(12):1364–1368.10.1002/jclp.22418CrossRefGoogle ScholarPubMed
Coccia, M. Sources, diffusion, and prediction in COVID-19 pandemic: lessons learned to face next health emergency. AIMS Public Health. 2023;10(1):145.10.3934/publichealth.2023012CrossRefGoogle ScholarPubMed
Qureshi, M. Scene safety and situational awareness in disaster response. In: Ciottone, GR, ed. Ciottone’s Disaster Medicine. Elsevier; 2024:281–289.10.1016/B978-0-323-80932-0.00042-2CrossRefGoogle Scholar
Ahmad, A, Maynard, SB, Desouza, KC, et al. How can organizations develop situation awareness for incident response: A case study of management practice. Comput Secur. 2021;101:102122.10.1016/j.cose.2020.102122CrossRefGoogle Scholar
Hugelius, K, Harada, N. What is disaster readiness among health care professionals? A systematic integrative review study. Disaster Med Public Health Prep. 2025;19:e57.10.1017/dmp.2025.58CrossRefGoogle ScholarPubMed
Apostolakis, KC, Dimitriou, N, Margetis, G, et al. DARLENE–Improving situational awareness of European law enforcement agents through a combination of augmented reality and artificial intelligence solutions. Open Res Eur. 2022;1:87.10.12688/openreseurope.13715.2CrossRefGoogle ScholarPubMed
Khorram-Manesh, A, Hedelin, A, Örtenwall, P. Regional coordination in medical emergencies and major incidents: plan, execute, and teach. Scand J Trauma Resusc Emerg Med. 2009;17(1):32.10.1186/1757-7241-17-32CrossRefGoogle ScholarPubMed
Hannah, ST, Jennings, PL, Nobel, OBY. Tactical military leader requisite complexity: Toward a referent structure. Military Psychol. 2010;22(4):412–449.10.1080/08995605.2010.513253CrossRefGoogle Scholar
Crundall, D, Van Loon, E, Baguley, T, Kroll, V. A novel driving assessment combining hazard perception, hazard prediction, and theory questions. Accid Anal Prev. 2021;149:105847.10.1016/j.aap.2020.105847CrossRefGoogle ScholarPubMed
Phattharapornjaroen, P, Carlström, E, Khorram-Manesh, A. Developing a conceptual framework for flexible surge capacity based on complexity and collaborative theoretical frameworks. Public Health. 2022;208:46–51.10.1016/j.puhe.2022.04.012CrossRefGoogle ScholarPubMed
Wong, L, Gerras, S, Kidd, W, et al. Strategic Leadership Competencies. Strategic Studies Institute of the US Army War College; 2022.Google Scholar
Ruiu, ML. Mismanagement of COVID-19: lessons learned from Italy. In: Wardman, JK, Löfstedt, R, eds. COVID-19. Routledge; 2022:175–188.Google Scholar
Cortes, AF, Herrmann, P. Strategic leadership of innovation: a framework for future research. Int J Manag Rev. 2021;23(2):224–243.10.1111/ijmr.12246CrossRefGoogle Scholar
Burkle, FM Jr, Bradt, DA, Ryan, BJ. Global public health database support to population-based management of pandemics and global public health crises, part I: the concept. Prehosp Disaster Med. 2021;36(1):95–104.10.1017/S1049023X20001351CrossRefGoogle ScholarPubMed
Bjerge, B, Clark, N, Fisker, P, et al. Technology and information sharing in disaster relief. PLoS One. 2016;11(9):e0161783.10.1371/journal.pone.0161783CrossRefGoogle ScholarPubMed
Khorram-Manesh, A, Gray, L, Goniewicz, K, et al. Care in emergencies and disasters: Can it be person-centered? Patient Educ Couns. 2024;118:108046.10.1016/j.pec.2023.108046CrossRefGoogle ScholarPubMed
Peta, D, Day, A, Lugari, WS, et al. Triage: A global perspective. J Emerg Nurs. 2023;49(6):814–825.10.1016/j.jen.2023.08.004CrossRefGoogle ScholarPubMed
Bazyar, J, Farrokhi, M, Salari, A, et al. Accuracy of triage systems in disasters and mass casualty incidents: a systematic review. Arch Acad Emerg Med. 2022;10(1):e32.Google ScholarPubMed
Khorram-Manesh, A. Teaching triage in disaster medicine–same subject, but different approach. Scand J Trauma Resusc Emerg Med. 2025;33(1):9.10.1186/s13049-025-01322-5CrossRefGoogle Scholar
Rådestad, M, Montán, KL, Rüter, A, et al. Attitudes towards and experience of the use of triage tags in major incidents: a mixed method study. Prehosp Disaster Med. 2016;31(4):376–385.10.1017/S1049023X16000480CrossRefGoogle ScholarPubMed
Varshney, K, Mallows, J, Hamd, M. Disaster triage tags: is one better than another? Emerg Med Australas. 2012;24(2):187–193.10.1111/j.1742-6723.2011.01523.xCrossRefGoogle Scholar
Burkle, FM Jr. Triage and the lost art of decoding vital signs: restoring physiologically based triage skills in complex humanitarian emergencies. Disaster Med Public Health Prep. 2018;12(1):76–85.10.1017/dmp.2017.40CrossRefGoogle ScholarPubMed
Burkle, FM. Pediatric reverse triage—uncomfortable but real decision-making for community preparedness. JAMA Pediatr. 2017;171(4):e164839–e164839.10.1001/jamapediatrics.2016.4839CrossRefGoogle ScholarPubMed
Cuthbertson, J, Penney, G. Ethical decision making in disaster and emergency management: A systematic review of the literature. Prehosp Disaster Med. 2023;38(5):622–627.CrossRefGoogle ScholarPubMed
Khorram-Manesh, A, Nordling, J, Carlström, E, et al. A translational triage research development tool: standardizing prehospital triage decision-making systems in mass casualty incidents. Scand J Trauma Resusc Emerg Med. 2021;29(1):119.10.1186/s13049-021-00932-zCrossRefGoogle ScholarPubMed
Khorram-Manesh, A, Burkle, FM Jr, Nordling, J, et al. Developing a translational triage research tool: part two—evaluating the tool through a Delphi study among experts. Scand J Trauma Resusc Emerg Med. 2022;30(1):48.10.1186/s13049-022-01035-zCrossRefGoogle ScholarPubMed
Khorram-Manesh, A, Carlström, E, Burkle, FM, et al. The implication of a translational triage tool in mass casualty incidents: part three: a multinational study, using validated patient cards. Scand J Trauma Resusc Emerg Med. 2023;31(1):88.10.1186/s13049-023-01128-3CrossRefGoogle ScholarPubMed
Khorram-Manesh, A, Plegas, P, Högstedt, Å, et al. Immediate response to major incidents: defining an immediate responder! Eur J Trauma Emerg Surg. 2020;46(6):1309–1320.10.1007/s00068-019-01133-1CrossRefGoogle ScholarPubMed
Vassallo, J, Moran, CG, Cowburn, P, Smith, J. New NHS prehospital major incident triage tool: from MIMMS to MITT. Emerg Med J. 2022;39(11):800–802.10.1136/emermed-2022-212569CrossRefGoogle ScholarPubMed
Vassallo, J, Cowburn, P, Park, C, et al. Ten second triage: A novel and pragmatic approach to major incident triage. Trauma. 2024;26(1):3–6.10.1177/14604086231156219CrossRefGoogle Scholar
Gray, DP, Dineen, M, Sidaway-Lee, K. The worried well. Br J Gen Pract. 2020;70(691):84.10.3399/bjgp20X708017CrossRefGoogle ScholarPubMed
Guggenheim, M. Introduction: disasters as politics–politics as disasters. Sociol Rev. 2014;62(1 suppl):1–16.10.1111/1467-954X.12121CrossRefGoogle Scholar
Oliver, AJ, Reeves, A. The politics of disaster relief. In: Scott, R and Kosslyn, S, eds. Emerging Trends in the Social and Behavioral Sciences. John Wiley & Sons; 2015:5.Google Scholar
Birchall, SJ, Kehler, S. Denial and discretion as a governance process: How actor perceptions of risk and responsibility hinder adaptation to climate change. Environ Sci Policy. 2023;147:1–10.10.1016/j.envsci.2023.05.017CrossRefGoogle Scholar
Goniewicz, K, Burkle, FM, Khorram-Manesh, A. Transforming global public health: climate collaboration, political challenges, and systemic change. J Infect Public Health. 2025;18(1):102615.10.1016/j.jiph.2024.102615CrossRefGoogle ScholarPubMed
Burkle, FM Jr. The politics of global public health in fragile states and ungoverned territories. PLoS Currents. 2017;9:ecurrents-dis.Google ScholarPubMed
Burkle, FM Jr, Hanfling, D. Political leadership in the time of crises: primum non nocere. PLoS Currents. 2015;7:ecurrents-dis.Google ScholarPubMed
Khorram-Manesh, A, Burkle, FM. Sociopathic narcissistic leadership: How about their victims? World Med Health Policy. 2024;16(1):19–36.10.1002/wmh3.588CrossRefGoogle Scholar
Khorram-Manesh, A, Goniewicz, K, Burkle, FM Jr. The impacts of narcissistic leadership on achieving the United Nations’ sustainable development goals—a scoping review. Challenges. 2024;15(3):37.CrossRefGoogle Scholar
Burkle, FM Jr, Khorram-Manesh, A, Goniewicz, K. The fate of global humanitarian assistance amidst growing health challenges. Disaster Med Public Health Prep. 2025;19:e167.10.1017/dmp.2025.10107CrossRefGoogle ScholarPubMed
Endsley, MR. Toward a theory of situation awareness in dynamic systems. In: Salas, E, ed. Situational Awareness. Routledge; 2017:9–42.10.4324/9781315087924-3CrossRefGoogle Scholar
Pearson, L, Pelling, M. The UN Sendai framework for disaster risk reduction 2015–2030: Negotiation process and prospects for science and practice. J Extreme Events. 2015;2(01):1571001.10.1142/S2345737615710013CrossRefGoogle Scholar
Pollack, AH, Mishra, SR, Apodaca, C, et al. Different roles with different goals: designing to support shared situational awareness between patients and clinicians in the hospital. J Am Med Inform Assoc. 2021;28(2):222–231.CrossRefGoogle ScholarPubMed
UK Gov. The UK Government Resilience Framework. Policy paper. Published December 2022. Accessed October 26, 2025. https://www.gov.uk/government/publications/the-uk-government-resilience-frameworkGoogle Scholar
Krichen, M, Abdalzaher, MS, Elwekeil, M, et al. Managing natural disasters: An analysis of technological advancements, opportunities, and challenges. Internet Things Cyber-Phys Syst. 2024;4:99–109.10.1016/j.iotcps.2023.09.002CrossRefGoogle Scholar
Marshall, A, Wilson, CA, Dale, A. Telecommunications and natural disasters in rural Australia: The role of digital capability in building disaster resilience. J Rural Stud. 2023;100:102996.CrossRefGoogle Scholar
Paulus, D, de Vries, G, Janssen, M, et al. The influence of cognitive bias on crisis decision-making: Experimental evidence on the comparison of bias effects between crisis decision-maker groups. Int J Disaster Risk Reduct. 2022;82:103379.10.1016/j.ijdrr.2022.103379CrossRefGoogle Scholar
Hansen, PM, Mikkelsen, S, Rehn, M. Communication in Sudden-Onset Major Incidents: Patterns and Challenges—Scoping Review. Disaster Med Public Health Prep. 2023;17:e482.CrossRefGoogle ScholarPubMed
Bonanno, GA, Chen, S, Bagrodia, R, Galatzer-Levy, IR. Resilience and disaster: flexible adaptation in the face of uncertain threat. Annu Rev Psychol. 2024;75(1):573–599.10.1146/annurev-psych-011123-024224CrossRefGoogle ScholarPubMed
Morley, G, Bradbury-Jones, C, Ives, J. The moral distress model: An empirically informed guide for moral distress interventions. J Clin Nurs. 2022;31(9-10):1309–1326.10.1111/jocn.15988CrossRefGoogle Scholar
Lowe, AE, Voo, TC, Lee, LM, et al. Uncertainty, scarcity, and transparency: Public health ethics and risk communication in a pandemic. Lancet Reg Health Am. 2022;16:100374.Google ScholarPubMed
Sultan, MAS, Carlström, E, Sørensen, JL, et al. Incorporating simulation exercises using collaborative tools into disaster and emergency medicine curriculum—A pilot survey among Saudi Arabian professionals. J Contingencies Crisis Manag. 2023;31(4):905–912.10.1111/1468-5973.12491CrossRefGoogle Scholar
Wennman, I, Jacobson, C, Carlström, E, et al. Organizational changes needed in disasters and public health emergencies: A qualitative study among managers at a major hospital. Int J Disaster Risk Sci. 2022;13(4):481–494.10.1007/s13753-022-00423-4CrossRefGoogle Scholar
Appleby-Arnold, S, Brockdorff, N, Callus, C. Developing a “culture of disaster preparedness”: The citizens’ view. Int J Disaster Risk Reduct. 2021;56:102133.CrossRefGoogle Scholar
Figure 0

Table 1. Shows the differences between DMS, disaster readiness, and disaster growth2,7-9

Figure 1

Figure 1. The various factors impacting different managerial levels in disaster and public health emergencies (by Khorram-Manesh A, an AI-image produced by Microsoft Copilot).

Figure 2

Figure 2. Translational triage tool (by Khorram-Manesh et al.).30–32

Figure 3

Table 2. Summarizing MARF by detailing the focus, application of SA and a DMS, and specific operational tools for each of the three organizational levels

Figure 4

Figure 3. An effective disaster and emergency response system comprises several key components. At its core is situational assessment (SA), the process of gathering and analyzing essential information, including critical political, social, and cultural factors. This assessment supports informed medical decision-making and enhances resource allocation through the concept of flexible surge capacity. Additionally, the use of translational triage tools helps prevent unnecessary fatalities caused by incompatible triage systems, especially within a multiagency collaborative framework.

Figure 5

Table 3. A brief explanation of the challenge and its impact on emergency response efforts