Defense Civil Support:
DOD, HHS, and DHS Should Use Existing Coordination Mechanisms to Improve Their Pandemic Preparedness
GAO-17-150: Published: Feb 10, 2017. Publicly Released: Feb 10, 2017.
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What GAO Found
The Department of Defense (DOD) has developed guidance and plans to direct its efforts to provide assistance in support of civil authorities—in particular the Departments of Health and Human Services (HHS) and Homeland Security (DHS)—in the event of a domestic outbreak of a pandemic disease. For example, the Department of Defense Global Campaign Plan for Pandemic Influenza and Infectious Diseases 3551-13 provides guidance to DOD and the military services on planning and preparing for a pandemic outbreak. DOD's Strategy for Homeland Defense and Support to Civil Authorities states that DOD often is expected to play a prominent supporting role to primary federal agencies. DOD also assists those agencies in the preparedness, detection, and response to other non-pandemic viruses, such as the recent outbreak of the Zika virus.
Figure 1: Photograph of the Aedes aegypti Mosquito Responsible for Spreading the Zika Virus
Source: Department of Defense | GAO-17-150
HHS and DHS have plans to guide their response to a pandemic, but their plans do not explain how they would respond in a resource-constrained environment in which capabilities like those provided by DOD are limited. DOD coordinates with the agencies, but existing coordination mechanisms among HHS, DHS, and DOD could be used to improve preparedness. HHS's Pandemic Influenza Plan is the departmental blueprint for its preparedness and response to an influenza pandemic. DHS's National Response Framework is a national guide on how federal, state, and local governments are to respond to such incidents. DOD, HHS, and DHS have mechanisms—such as interagency working groups, liaison officers, and training exercises—to coordinate their response to a pandemic. For example, training exercises are critical in preparing these agencies to respond to an incident by providing opportunities to test plans, improve proficiency, and assess capabilities and readiness. These existing mechanisms provide the agencies opportunities to improve their preparedness and response to a pandemic. HHS and DHS plans do not specifically identify what resources would be needed to support a response to a pandemic in which demands exceeded federal resources. These officials stated that there would be no way of knowing in advance what resources would be required. HHS and DHS are in the process of updating their plans and thus have an opportunity to coordinate with each other and with DOD to determine the appropriate actions to take should DOD's support be limited.
Why GAO Did This Study
The U.S. Army estimates that if a severe infectious disease pandemic were to occur today, the number of U.S. fatalities could be almost twice the total number of battlefield fatalities in all of America's wars since the American Revolution in 1776. A pandemic occurs when an infectious agent emerges that can be efficiently transmitted between humans and has crossed international borders. DOD's day-to-day functioning and the military's readiness and operations abroad could be impaired if a large percentage of its personnel are sick or absent, and DOD's assistance to civil authorities might be limited.
House Report 114-102 included a provision for GAO to assess DOD's planning and coordination to support civil authorities during a pandemic. This report assesses the extent to which (1) DOD has guidance and plans for supporting civil authorities in the event of a domestic outbreak of a pandemic disease and (2) HHS and DHS have plans to respond to a pandemic if DOD support capabilities are limited, and they have mechanisms to coordinate their pandemic preparedness and response. GAO reviewed agency pandemic guidance and plans, interagency coordination mechanisms, and pandemic-related exercises and after-action reports.
What GAO Recommends
GAO recommends that DOD, HHS, and DHS use existing coordination mechanisms to explore opportunities to improve preparedness and response to a pandemic if DOD's capabilities are limited. DOD, HHS, and DHS concurred with GAO's recommendations.
For more information, contact Joe Kirschbaum, at (202) 512-9971 or KirschbaumJ@gao.gov.
Recommendations for Executive Action
Status: Closed - Implemented
Comments: DOD concurred with this recommendation. DOD hosted Hidden Peril V table top exercise on May 23, 2017. Hidden Peril V tested how an interagency response to a domestic pandemic influenza outbreak would occur and included what HHS and FEMA would do if DOD support was limited. DOD issued an after-action report on the results of the table top exercise on June 27, 2017. The results of the exercise showed that HHS and FEMA will need to de-conflict their leadership roles in a public health crisis, and HHS will need to work with Congress to determine how they might more quickly gain access to funding that will allow them to surge response efforts to a pandemic. Also, the after-action report identified a list of planning considerations to improve response during a pandemic at all levels of government. Specifically, the report recommended that: (1) a lead federal department or agency must be clearly identified for complex domestic incidents near or just under the Stafford Act threshold; (2) funding must be received quickly by the identified lead federal department or agency in cases of complex domestic incidents, such as pandemic response; (3) federal pandemic response guidance must incorporate awareness of states' varying levels of response capacity, capability, and preparedness, and must consider second- and third-order consequences of federal decisions or recommendations on state and local governments and populations; (4) political leadership must be engaged early and often to ensure understanding of policy decisions' potential unintended consequences; (5) preplanned messaging, coordinated thoroughly from the federal through local levels and cognizant of local realities, can facilitate a smoother whole-of-government response; (6) the Intelligence Community and the public health network must form a comprehensive picture of the disease outbreak in order to provide tailored and timely information to the federal, state, and local responders to slow the spread of the disease; and (7) the idiosyncratic nature of all stages of a pandemic necessitates thorough contingency planning, including the expectation that the federal government workforce will be compromised. Subsequent to the table top exercise, DOD documented the following recommendations for HHS and FEMA: (1) HHS and DHS (FEMA) should collect data to project the number and types of medical and support personnel and equipment needed to respond to a pandemic; (2) ensure capabilities are accessible and available for rapid implementation; and (3) HHS and DHS (FEMA) should pre-identify medical capabilities from federal, state, local, public, and private sector entities and establish arrangements to respond as the demand warrants. Based on these actions, this recommendation is closed as implemented.
Recommendation: As DOD plans to respond to a pandemic, the Secretary of Defense should direct the Under Secretary of Defense for Policy and other DOD officials, as appropriate, to use DOD's existing coordination mechanisms with HHS and the Federal Emergency Management Agency (FEMA) to explore opportunities to improve their preparedness and response to a pandemic if DOD's capabilities are limited.
Agency Affected: Department of Defense
Status: Closed - Implemented
Comments: HHS concurred with this recommendation. HHS and the Office of the Assistant Secretary for Preparedness and Response (ASPR) has been working with DOD and DHS through the National Security Council to draft a National Biodefense Strategy in keeping with Section 1086 of the National Defense Authorization Act for Fiscal Year 2017 (P.L. 114-328). While the National Biodefense Strategy is not specific to any pandemic planning and preparedness, it incorporates many of the same levels of communication in keeping with the broader concept of biosecurity. ASPR chairs the Public Health Emergency Medical Countermeasures Enterprise (PHEMCE). Established in 2006, PHEMCE is the federal coordinating body that oversees the whole medical countermeasure lifecycle and assures that federal departments and agencies are coordinated and working efficiently together. PHEMCE is led by ASPR, in partnership with other HHS agencies, the National Institutes of Health, the Centers for Disease Control and Prevention, and the Food and Drug Administration, and interagency partners such as the DOD, DHS, the Department of Veterans Affairs, and the Department of Agriculture. As such, ASPR's coordination with DOD and DHS on medical countermeasures that address infectious disease strains with pandemic potential takes place under the PHEMCE construct. Additionally, DOD is represented in all of the PHEMCE Integrated Program Teams and the Portfolio Advisory Committee. In September 2018, in response to a statutory requirement in the National Defense Authorization Act for Fiscal Year 2017, the White House released the National Biodefense Strategy and National Security Presidential Memorandum-14 (NSPM-14), Support for National Biodefense (September 18, 2018), which establishes a governance structure to guide the strategy's implementation. With these actions and issuance of the strategy, HHS met the intent of our recommendation and the recommendation is closed as implemented.
Recommendation: As HHS plans to respond to a pandemic, the Secretary of Health and Human Services should direct the Assistant Secretary for Preparedness and Response to use HHS's existing coordination mechanisms with DOD and FEMA to explore opportunities to improve their preparedness and response to a pandemic if DOD's capabilities are limited.
Agency Affected: Department of Health and Human Services
Status: Closed - Implemented
Comments: DHS concurred with this recommendation. FEMA continues to collaborate with interagency partners, including DOD and HHS, to coordinate and plan for a variety of hazards, including pandemics. HHS is the Lead Federal Agency for federal public health and medical response, which includes pandemics. FEMA coordinates federal support for consequence management. Federal interagency partners are postured to support the whole community response to a potential pandemic threat posed by emerging or re-emerging viral pathogens and support HHS, as requested, to assist state, local, tribal, and territorial partners with related preparedness and response activities. As the interagency coordinator for planning for a variety of hazards, FEMA maintains several plans that may be used during an interagency response to a pandemic threat, such as the Federal Response Interagency Operations Plan, which is an all-hazards plan that describes how the federal government coordinates its efforts to save lives, protect property and the environment, and meet basic human needs following an emergency or disaster; the Biological Incident Annex to the Federal Interagency Operations Plan, which provides strategic guidance for the coordination of the interagency during response to a biologic incident, including pandemics; and the Pandemic Crisis Action Plan, which provides strategic-level responsibilities in preparing and responding to a pandemic influenza outbreak. Within the Pandemic Crisis Action Plan, the synchronization matrix identifies federal interagency activities within each phase of a pandemic response, and clarifies DOD, HHS, Centers for Disease Control and Prevention (CDC), and Emergency Support Function roles and responsibilities. In May 2017, FEMA participated in DOD's table topic exercise, known as Hidden Peril V, with HHS, CDC, DOD, Department of Transportation, and a host of federal department and agencies, as well as the National Security Council staff. An after-action report was developed on the results of this exercise, and FEMA will review the results of the after-action report from the table top exercise and adjust the Pandemic Crisis Action Plan and work with federal partners in addressing these report findings. On September 4, 2018, FEMA provided GAO with copies of the after-action report developed as a result of the Hidden Peril V table top exercise, the final Pandemic Crisis Action Plan, evidence to show that the Emergency Support Function Leadership Group concurred with the Pandemic Crisis Action Plan, and evidence to show that FEMA made adjustments to the Pandemic Crisis Action Plan and worked with federal partners to address the seven key findings. These documents demonstrate that FEMA continues to make progress to improve its preparedness and response to a pandemic if DOD's capabilities are limited. In the spring of 2017, FEMA, along with interagency partners that make up the Emergency Support Function Leadership Group, took steps to update the 2017 Pandemic Crisis Action Plan. FEMA issued the 2018 Pandemic Crisis Action Plan in January 2018. The plan is an interagency operations plan specific to a pandemic threat. The current 2018 plan contains updated and refined coordination structures and a synchronization matrix that identifies federal interagency activities within each phase of a pandemic response. In addition, the plan clarifies DOD, HHS, CDC, and Emergency Support Function roles and responsibilities. Based on these actions, this recommendation is closed as implemented.
Recommendation: As DHS, through FEMA, plans to respond to a pandemic, the Secretary of Homeland Security should direct the Administrator of FEMA to use FEMA's existing coordination mechanisms with DOD and HHS to explore opportunities to improve their preparedness and response to a pandemic if DOD's capabilities are limited.
Agency Affected: Department of Homeland Security: Directorate of Emergency Preparedness and Response: Federal Emergency Management Agency