Influenza Pandemic
DOD Combatant Commands' Preparedness Efforts Could Benefit from More Clearly Defined Roles, Resources, and Risk Mitigation Gao ID: GAO-07-696 June 20, 2007An influenza pandemic could impair the military's readiness, jeopardize ongoing military operations abroad, and threaten the day-to-day functioning of the Department of Defense (DOD) due to a large percentage of sick or absent personnel. GAO was asked to examine DOD's pandemic influenza planning and preparedness efforts. GAO previously reported that DOD had taken numerous actions to prepare departmentwide, but faced four management challenges as it continued its efforts. GAO made recommendations to address these challenges and DOD generally concurred with them. This report focuses on DOD's combatant commands (COCOM) and addresses (1) actions the COCOMs have taken to prepare and (2) management challenges COCOMs face going forward. GAO reviewed guidance, plans, and after-action reports and interviewed DOD officials and more than 200 officials at the 9 COCOMs.
COCOMs have taken numerous management and operational actions to prepare for an influenza pandemic, and the COCOMs' efforts are evolving. Each of DOD's nine COCOMs has established or intends to establish a working group to prepare for an influenza pandemic. Additionally, eight of the nine COCOMs have developed or are developing a pandemic influenza plan. Half of the COCOMs have conducted exercises to test their pandemic influenza plans and several are taking steps to address lessons learned. Five of the nine COCOMs have started to use various media, training programs, and outreach events to inform their personnel about pandemic influenza. Each of the geographic COCOMs has worked or plans to work with nations in its area of responsibility to raise awareness about and assess capabilities for responding to avian and pandemic influenza. Although COCOMs have taken numerous actions, GAO identified three management challenges that may prevent the COCOMs from being fully prepared to effectively protect personnel and perform missions during an influenza pandemic, two of which are related to issues GAO previously recommended that DOD address. First, the roles, responsibilities, and authorities of key organizations relative to others involved in DOD's planning efforts remained unclear in part due to the continued lack of sufficiently detailed guidance from the Secretary of Defense or his designee. As a result, the unity and cohesiveness of DOD's efforts could be impaired and the potential remains for confusion and gaps or duplication in actions taken by the COCOMs relative to the military services and other DOD organizations, such as in completing actions assigned to DOD in the Implementation Plan for the National Strategy for Pandemic Influenza. Second, GAO identified a disconnect between the COCOMs' planning and preparedness activities and resources, including funding and personnel, to complete these activities, in part, because DOD's guidance does not identify the resources required to complete these activities. The continued lack of a link between planning and preparedness activities and resources may limit the COCOMs' ability to effectively prepare for and respond to an influenza pandemic, including COCOMs' ability to exercise pandemic influenza plans in the future. Third, GAO identified factors that are beyond the COCOMs' control--such as limited detailed guidance from other federal agencies on support expected from DOD, lack of control over DOD's stockpile of antivirals, limited information on decisions that other nations may make during an influenza pandemic, reliance on civilian medical providers for medical care, and reliance on military services for medical materiel--that they have not yet fully planned how to mitigate. While GAO recognizes the challenge of pandemic influenza planning, not yet developing options to mitigate the effects of factors that are beyond their control may place at risk the COCOM commanders' ability to protect their personnel and perform missions during an influenza pandemic. For example, if a nation decides to close its borders at the start of a pandemic, COCOMs and installations may not be able to obtain needed supplies, such as antivirals.
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Director: Team: Phone:GAO-07-696, Influenza Pandemic: DOD Combatant Commands' Preparedness Efforts Could Benefit from More Clearly Defined Roles, Resources, and Risk Mitigation
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Report to the Committee on Oversight and Government Reform, House of
Representatives:
United States Government Accountability Office:
GAO:
June 2007:
Influenza Pandemic:
DOD Combatant Commands' Preparedness Efforts Could Benefit from More
Clearly Defined Roles, Resources, and Risk Mitigation:
GAO-07-696:
GAO Highlights:
Highlights of GAO-07-696, a report to the Committee on Oversight and
Government Reform, House of Representatives
Why GAO Did This Study:
An influenza pandemic could impair the military‘s readiness, jeopardize
ongoing military operations abroad, and threaten the day-to-day
functioning of the Department of Defense (DOD) due to a large
percentage of sick or absent personnel. GAO was asked to examine DOD‘s
pandemic influenza planning and preparedness efforts. GAO previously
reported that DOD had taken numerous actions to prepare departmentwide,
but faced four management challenges as it continued its efforts. GAO
made recommendations to address these challenges and DOD generally
concurred with them. This report focuses on DOD‘s combatant commands
(COCOM) and addresses (1) actions the COCOMs have taken to prepare and
(2) management challenges COCOMs face going forward. GAO reviewed
guidance, plans, and after-action reports and interviewed DOD officials
and more than 200 officials at the 9 COCOMs.
What GAO Found:
An influenza pandemic could impair the military‘s readiness, jeopardize
ongoing military operations abroad, and threaten the day-to-day
functioning of the Department of Defense (DOD) due to a large
percentage of sick or absent personnel. GAO was asked to examine DOD‘s
pandemic influenza planning and preparedness efforts. GAO previously
reported that DOD had taken numerous actions to prepare departmentwide,
but faced four management challenges as it continued its efforts. GAO
made recommendations to address these challenges and DOD generally
concurred with them. This report focuses on DOD‘s combatant commands
(COCOM) and addresses (1) actions the COCOMs have taken to prepare and
(2) management challenges COCOMs face going forward. GAO reviewed
guidance, plans, and after-action reports and interviewed DOD officials
and more than 200 officials at the 9 COCOMs.
What GAO Recommends:
GAO recommends that DOD take steps to clarify the COCOMs‘ roles and
responsibilities for pandemic influenza-related efforts, identify the
sources and types of resources needed for the COCOMs to accomplish
these efforts, and develop options to mitigate the effects of factors
that are outside of their control. DOD concurred with each of these
recommendations.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-696].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Davi M. D'Agostino at
(202) 512-5431 or dagostinod@gao.gov.
[End of Section]
Contents:
Letter:
Results in Brief:
Background:
COCOMs Have Taken Numerous Actions to Prepare for an Influenza Pandemic:
COCOMs Face Three Management Challenges as They Continue to Prepare for
an Influenza Pandemic:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Actions Assigned to DOD as a Lead Agency in the National
Implementation Plan:
Appendix II: Scope and Methodology:
Appendix III: Comments from the Department of Defense:
Appendix IV: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Summary of COCOMs' Actions to Prepare for an Influenza
Pandemic:
Table 2: COCOM Perceptions of Responsibility for Actions Assigned to
DOD:
Figures:
Figure 1: Geographic COCOMs' Areas of Responsibility:
Figure 2: Comparison of WHO Pandemic Phases and Federal Government
Stages:
Figure 3: Timeline of COCOMs' Pandemic Influenza Planning Efforts:
Figure 4: Official Provides Information about Pandemic Influenza at
PACOM's Outreach Event:
Abbreviations:
ASD: Assistant Secretary of Defense:
ASD(HD&ASA): Assistant Secretary of Defense for Homeland Defense and
Americas' Security Affairs:
CENTCOM: Central Command:
COCOM: Combatant command:
DOD: Department of Defense:
EUCOM: European Command:
JFCOM: Joint Forces Command:
NORTHCOM: Northern Command:
PACOM: Pacific Command:
SOCOM: Special Operations Command:
SOUTHCOM: Southern Command:
STRATCOM: Strategic Command:
TRANSCOM: Transportation Command:
WHO: World Health Organization:
United States Government Accountability Office:
Washington, DC 20548:
June 20, 2007:
The Honorable Henry A. Waxman:
Chairman:
The Honorable Tom Davis:
Ranking Member:
Committee on Oversight and Government Reform:
House of Representatives:
An influenza pandemic--a novel influenza virus that has the ability to
infect and be passed efficiently among humans--could significantly
impair the military's readiness, jeopardize ongoing military operations
abroad, and threaten the day-to-day functioning of the Department of
Defense (DOD) due to a large percentage of sick or absent personnel.
The vulnerability of U.S. armed forces to an influenza pandemic was
demonstrated during World War I when at least 43,000 U.S.
servicemembers died--about half of all of the deaths of U.S.
servicemembers during World War I--due to influenza or influenza-
related complications, and another 1 million servicemembers were
hospitalized, which limited the military's ability to continue ongoing
missions. According to the Centers for Disease Control and Prevention,
the "Spanish flu" pandemic of 1918-1919 killed at least 50 million
people worldwide, including approximately 675,000 in the United
States.[Footnote 1] According to the World Health Organization (WHO),
it is not a question of if, but when, another influenza pandemic will
occur. During the peak weeks of an outbreak of a severe influenza
pandemic, the Homeland Security Council estimates that 40 percent of
the U.S. workforce might not be at work due to illness, the need to
care for family members who are sick, or fear of becoming infected. DOD
military and civilian personnel and contractors would not be immune and
the department would face a similar absentee rate.
Recent concerns about the possibility of an influenza pandemic have
arisen due to an unprecedented outbreak of H5N1, a deadly strain of
avian influenza which began in Hong Kong in 1997 and spread among bird
populations in parts of Asia, the Middle East, Europe, and Africa, with
limited infections in humans. According to WHO, 309 human cases of H5N1
resulting in 187 human deaths had been reported worldwide as of May 31,
2007. Scientists and public health officials agree that the rapid
spread of the virus in birds and the occurrence of limited infections
in humans have increased the risk that this disease may mutate into a
form that is easily transmissible among humans. According to WHO, three
conditions must be met before an influenza pandemic begins: (1) a new
influenza virus subtype that has not previously circulated in humans
must emerge, (2) the virus must be capable of causing disease in
humans, and (3) the virus must be capable of being passed easily among
humans. The H5N1 virus currently meets the first two of these three
conditions.
To address the potential threat of an influenza pandemic, the Homeland
Security Council issued its National Strategy for Pandemic Influenza in
November 2005.[Footnote 2] The Implementation Plan for the National
Strategy for Pandemic Influenza (national implementation
plan),[Footnote 3] which was released in May 2006, tasked each federal
agency with developing its own implementation plan that addresses two
issues: (1) how it would address the actions assigned to the agency and
(2) its approach to employee safety, continuity of operations, and
communications with stakeholders departmentwide. DOD finalized its
implementation plan for pandemic influenza in August 2006 and released
the plan publicly in May 2007.[Footnote 4] Of the more than 300 actions
in the national implementation plan, DOD is responsible for 114
actions--31 actions as a lead agency and 83 actions as a supporting
agency.[Footnote 5] Appendix I lists these actions, the implementation
deadline, and the lead DOD organization responsible for implementing
the action.
DOD began its departmentwide planning and preparedness efforts in
September 2004, when the Assistant Secretary of Defense (ASD) for
Health Affairs issued guidance to the military departments on preparing
for an influenza pandemic. The Deputy Secretary of Defense designated
the ASD for Homeland Defense and Americas' Security Affairs
(ASD[HD&ASA]), within the Office of the Under Secretary of Defense for
Policy, as the lead for DOD's pandemic influenza planning
efforts,[Footnote 6] and DOD identified functional leads to oversee the
31 actions assigned to DOD as a lead agency in the national
implementation plan. The ASD(HD&ASA) is the lead for those actions
related to providing defense support of civil authorities, the ASD for
Health Affairs is the functional lead for force health protection
actions, and the Joint Staff oversees the combatant commands' (COCOM)
planning and implementation efforts. In August 2006, the Secretary of
Defense named the U.S. Northern Command (NORTHCOM) the lead COCOM for
directing, planning, and synchronizing DOD's global response to
pandemic influenza.
As operational commanders, DOD's unified COCOMs are an essential part
of the department's pandemic influenza planning. There are currently
nine COCOMs--five with geographic responsibilities and four with
functional responsibilities.[Footnote 7] The five COCOMs with
geographic responsibilities are the U.S. Central Command (CENTCOM),
U.S. European Command (EUCOM), NORTHCOM, U.S. Pacific Command (PACOM),
and U.S. Southern Command (SOUTHCOM). Their geographic areas of
responsibility are shown in figure 1. The four functional COCOMs are
the U.S. Joint Forces Command (JFCOM) which, among other things,
engages in joint training and force provision; U.S. Special Operations
Command (SOCOM), which trains, equips, and deploys special operations
forces to other COCOMs and leads counterterrorist missions worldwide;
U.S. Strategic Command (STRATCOM), whose missions include space and
information operations; missile defense; global command and control;
intelligence, surveillance, and reconnaissance; strategic deterrence;
and integration and synchronization of DOD's departmentwide efforts in
combating weapons of mass destruction; and U.S. Transportation Command
(TRANSCOM), which provides air, land, and sea transportation for DOD.
Figure 1: Geographic COCOMs' Areas of Responsibility:
[See PDF for image]
Notes: Areas of responsibility are as of October 1, 2006. In February
2007, the Secretary of Defense announced that DOD will establish a
sixth COCOM with geographic responsibilities--the U.S. Africa Command-
-which is expected to become operational by September 2008.
Responsibility for African operations currently is divided among EUCOM,
CENTCOM, and PACOM.
[A] The state of Alaska is assigned to NORTHCOM's area of
responsibility. Forces based in Alaska, however, remain assigned to
PACOM.
[End of figure]
You asked that we examine DOD's planning and preparedness efforts for
an influenza pandemic. In September 2006, we issued a report on DOD's
efforts to prepare its workforce for an influenza pandemic.[Footnote 8]
We reported that since September 2004, DOD had taken a number of
actions to prepare for an influenza pandemic; however, DOD faced four
management challenges for its ongoing pandemic influenza preparedness
efforts. We found that DOD had not defined lead and supporting roles
and responsibilities, oversight mechanisms, or goals and performance
measures for its planning efforts; had not requested funding to support
pandemic influenza preparedness; had not fully defined or communicated
which types of personnel--military and civilian personnel, contractors,
dependents, and beneficiaries--would be included in vaccine and
antiviral distribution; and had not fully developed a communications
strategy. We recommended that DOD take actions to address these issues.
DOD generally concurred with our recommendations, but had not yet taken
actions to address our recommendations. While our September 2006 report
focused on DOD's planning and preparedness efforts departmentwide, this
report focuses on the COCOMs' planning and preparedness efforts for an
influenza pandemic. Specifically, this report addresses (1) the actions
the COCOMs have taken to prepare for an influenza pandemic and (2)
management challenges the COCOMs face as they continue their planning
and preparedness efforts.
To address these objectives, we reviewed drafts of the five geographic
COCOMs' plans and one functional COCOM's plan that were available at
the time of our review. We did not evaluate the plans; rather, we used
the plans to determine the actions the COCOMs have taken and plan to
take to prepare for an influenza pandemic. We also reviewed a November
2005 Joint Staff planning order, an April 2007 Joint Staff planning
order, DOD's implementation plan for pandemic influenza, the
Implementation Plan for the National Strategy for Pandemic Influenza,
DOD budget requests and appropriations, and after-action reports for
exercises. We met with more than 200 officials involved in pandemic
influenza planning and preparedness efforts at the nine COCOMs, service
and special operations subcomponents at two COCOMs (EUCOM and PACOM),
and U.S. Forces Korea. We also met with officials from the Office of
the ASD(HD&ASA), the Office of the ASD for Health Affairs, and the
Joint Staff. Additionally, we met with officials at the Department of
State to discuss their pandemic influenza planning and preparedness
efforts in relation to the COCOMs' efforts abroad. Finally, we compared
COCOMs' actions to date with best practices we have identified in prior
work on risk management, influenza pandemics, emergency preparedness,
and general management. We conducted our review from September 2006
through April 2007 in accordance with generally accepted government
auditing standards. Further details on our scope and methodology are in
appendix II.
Results in Brief:
DOD's COCOMs have taken numerous actions to prepare for an influenza
pandemic, including management actions, such as establishing working
groups, and operational actions, such as coordinating with other
nations. The COCOMs' pandemic influenza planning and preparedness
efforts are evolving. At the time of our review, each of the COCOMs had
established or intended to establish a working group to oversee plan
development and work on other aspects of pandemic influenza
preparation. Additionally, eight of the nine COCOMs had developed or
were developing a pandemic influenza plan. Although SOCOM's
headquarters is not developing a pandemic influenza plan, officials
said they expect each of the geographically-based special operations
commands will develop an annex for their geographic COCOMs' plans. To
test their pandemic influenza plans, half of the COCOMs have conducted
a pandemic or avian influenza-specific exercise or included a pandemic
or avian influenza scenario within another exercise, and nearly all of
the COCOMs plan to address pandemic influenza in future exercises.
Several of the COCOMs are taking steps to address some lessons learned
from the exercises. Five of the nine COCOMs have started to use various
strategies, including using various media outlets, training programs,
and outreach events, to inform their personnel--including military and
civilian personnel, contractors, dependents, and beneficiaries--about
pandemic influenza. For example, PACOM held an outreach event that
combined providing seasonal flu vaccinations with distributing
information about pandemic influenza. Each of the geographic COCOMs has
worked or plans to work with nations in its area of responsibility to
raise awareness about and assess capabilities for responding to avian
and pandemic influenza. For example, CENTCOM has performed assessments
and identified gaps for Afghanistan's pandemic influenza preparedness
and response.
Although COCOMs have taken numerous actions, we identified three
management challenges that may prevent the COCOMs from being fully
prepared to effectively protect personnel and perform their missions
during an influenza pandemic. Two of these challenges--the lack of
clearly defined roles and responsibilities and the lack of information
on required resources--are related to departmentwide issues that we
recommended DOD take actions to address in our September 2006 report,
but DOD has not yet taken action to address them. The challenges are as
follows:
* The roles, responsibilities, and authorities of key organizations
involved in DOD's pandemic influenza planning and preparedness efforts
relative to other organizations leading and supporting the department's
pandemic influenza planning efforts--including NORTHCOM as the lead for
DOD's planning and the individual COCOMs--remained unclear because of
the continued lack of sufficiently detailed guidance from the Secretary
of Defense or his designee. We have previously reported that, as with
preparing for and responding to any other type of disaster, leadership
roles and responsibilities must be clearly defined, effectively
communicated, and well understood to facilitate rapid and effective
decision making.[Footnote 9] As a result of not yet issuing guidance
fully and clearly defining the roles, responsibilities, authorities,
and relationships of key organizations, such as offices within the
Office of the Secretary of Defense, the military services, and the
COCOMs, the unity and cohesiveness of DOD's pandemic influenza
preparation could be impaired. Furthermore, the potential remains for
confusion and gaps or duplication in actions taken by the COCOMs
relative to other DOD organizations, such as the military services. For
example, officials from the Office of the ASD(HD&ASA) and the Joint
Staff said the COCOMs were responsible for completing few actions
assigned to DOD in the national implementation plan; however, COCOM
officials reported that they were, in part, responsible for
implementing between 12 and 18 of these actions.
* Second, we identified a disconnect between the COCOMs' planning and
preparedness activities and resources to complete these activities in
part because DOD's guidance for the COCOMs' planning efforts does not
identify the resources required to complete these activities. We have
previously reported that information on required resources is critical
for making sound analyses of how to pursue goals.[Footnote 10] Without
realistic information on required resources, decision makers cannot
determine whether a strategy to achieve those goals is realistic and
cost effective, or make trade-offs against other funding priorities.
The continued lack of a link between planning and preparedness
activities and resources may limit the COCOMs' ability to effectively
prepare for and respond to an influenza pandemic. For example, EUCOM
and PACOM officials said a lack of resources will limit their ability
to exercise their pandemic influenza plans in the future.
* Third, we identified factors that are beyond the COCOMs' control--
such as limited detailed guidance from other federal agencies on the
support expected from DOD, lack of control over DOD's stockpile of
antivirals, limited information on decisions that other nations may
make during an influenza pandemic, reliance on civilian medical
providers for medical care, and reliance on military services for
medical materiel--that they have not yet fully planned how to mitigate.
We have recommended a comprehensive risk-management approach, including
putting steps in place to reduce the effects of any outbreak that does
occur, as a framework for decision making.[Footnote 11] Some COCOMs
have taken steps to mitigate the effects of these factors that are
beyond their control; however, planning officials from at least one
COCOM said they will not develop specific plans to address some of
these factors until they receive more information. Planning officials
from three COCOMs and two service subcomponents said that planning to
provide support at the last minute could lead to a less effective and
less efficient use of resources. While we recognize the difficulty of
planning for an influenza pandemic, not yet developing options to
mitigate the effects of factors that are beyond their control may place
at risk the COCOM commanders' ability to protect their personnel,
including military and civilian personnel, contractors, dependents, and
beneficiaries, and perform their missions during an influenza pandemic.
For example, if a nation decides to close its borders at the start of a
pandemic, COCOMs and installations may not be able to obtain needed
supplies, such as antivirals.
We are making three recommendations to improve the COCOMs' ongoing
pandemic influenza planning and preparedness efforts. Specifically, we
recommend that DOD take steps to clarify the COCOMs' roles and
responsibilities in DOD's pandemic influenza planning and preparedness
efforts, identify the sources and types of resources needed for the
COCOMs to accomplish their pandemic influenza-related efforts, and
develop options to mitigate the effects of factors that are beyond
their control.
We provided a draft of this report to DOD and the Department of State
in April 2007 for their review and comment. In written comments on a
draft of this report, DOD concurred with all of our recommendations and
noted that the department is confident that future plans will
adequately address specific roles, resources, and risk mitigation. The
Department of State had no comments. DOD also provided us with
technical comments, which we incorporated in the report, as
appropriate. DOD's comments can be found in appendix III.
Background:
Planning for an influenza pandemic is a difficult and daunting task,
particularly because so much is currently unknown about a potential
pandemic. While some scientists and public health experts believe that
the next influenza pandemic could be spawned by the H5N1 avian
influenza strain, it is unknown when an influenza pandemic will occur,
where it will begin, or whether a variant of H5N1 or some other strain
would be the cause. Moreover, the severity of an influenza pandemic, as
well as the groups of people most at risk for infection, cannot be
accurately predicted. Past pandemics have spread worldwide within
months and a future pandemic is expected to spread even more quickly
given modern travel patterns. The implication of such a rapid spread is
that many, if not most, countries will have minimal time to implement
preparations and responses once a pandemic virus begins to spread.
However, as we have previously reported, despite all of these
uncertainties, sound planning and preparedness could lessen the impact
of any influenza pandemic.[Footnote 12]
Preparing for an influenza pandemic can be helpful not only to lessen a
pandemic's impact, but also to help prepare for other disasters that
may occur. As we have previously reported, the issues associated with
preparation for and response to an influenza pandemic are similar to
those for any other type of disaster: clear leadership roles and
responsibilities, authority, and coordination; risk management;
realistic planning, training, and exercises; assessing and building the
capacity needed to effectively respond and recover; effective
information sharing and communication; and accountability for the
effective use of resources.[Footnote 13] At the same time, a pandemic
poses some unique challenges. Rather than being localized in particular
areas and occurring within a short period of time, as do disasters such
as earthquakes, explosions, or terrorist incidents, an influenza
pandemic is likely to affect wide areas of the world and continue for
weeks or months. Past pandemics have spread globally in two and
sometimes three waves, according to WHO, and a pandemic is likely to
come in waves lasting months, according to the national implementation
plan. Additionally, responding to an influenza pandemic would be more
challenging than dealing with annual influenza. Each year, annual
influenza causes approximately 226,000 hospitalizations and 36,000
deaths in the United States. According to WHO, an influenza pandemic
would spread throughout the world very quickly, usually in less than a
year, and could sicken more than a quarter of the global population,
including young, healthy individuals who are not normally as affected
by the annual flu.
WHO defines the emergence of an influenza pandemic in six phases (see
fig. 2). Based on this definition, the world currently is in phase 3,
in which there are human infections from a new influenza subtype, but
no or very limited human-to-human transmission of the disease. In
addition, the Homeland Security Council developed "stages" that
characterize the outbreak in terms of the threat that the pandemic
virus poses to the U.S. population. These stages, also shown in figure
2, provide a framework for a federal government response to an
influenza pandemic. Currently there are new domestic animal outbreaks
in an at-risk country, which corresponds to the federal government's
stage 0.
Figure 2: Comparison of WHO Pandemic Phases and Federal Government
Stages:
[See PDF for image]
Source: Homeland Security
[End of figure]
COCOMs Have Taken Numerous Actions to Prepare for an Influenza Pandemic:
COCOMs have taken numerous management and operational actions to
prepare for an influenza pandemic and the COCOMs' efforts are evolving.
While the COCOMs are at different stages in their planning and
preparedness efforts, each has taken actions to plan and prepare for an
influenza pandemic. These actions include establishing working groups,
developing plans, exercising plans, implementing strategies to inform
personnel about pandemic influenza, and coordinating with other
nations. Table 1 summarizes the COCOMs' actions to prepare for an
influenza pandemic.
Table 1: Summary of COCOMs' Actions to Prepare for an Influenza
Pandemic:
Combatant command: CENTCOM;
Established working groups: X;
Developed plans: X;
Conducted exercises: X;
Informed personnel: [Empty];
Coordinated with other nations: X.
Combatant command: EUCOM;
Established working groups: X;
Developed plans: X;
Conducted exercises: X;
Informed personnel: X;
Coordinated with other nations: X.
Combatant command: JFCOM;
Established working groups: [Empty];
Developed plans: X;
Conducted exercises: [Empty];
Informed personnel: [Empty];
Coordinated with other nations: [Empty].
Combatant command: NORTHCOM;
Established working groups: X;
Developed plans: X;
Conducted exercises: X;
Informed personnel: X;
Coordinated with other nations: X.
Combatant command: PACOM;
Established working groups: X;
Developed plans: X;
Conducted exercises: X;
Informed personnel: X;
Coordinated with other nations: X.
Combatant command: SOCOM;
Established working groups: [Empty];
Developed plans: a;
Conducted exercises: [Empty];
Informed personnel: [Empty];
Coordinated with other nations: [Empty].
Combatant command: SOUTHCOM;
Established working groups: X;
Developed plans: X;
Conducted exercises: [Empty];
Informed personnel: X;
Coordinated with other nations: X.
Combatant command: STRATCOM;
Established working groups: X;
Developed plans: X;
Conducted exercises: X;
Informed personnel: X;
Coordinated with other nations: [Empty].
Combatant command: TRANSCOM;
Established working groups: X;
Developed plans: X;
Conducted exercises: [Empty];
Informed personnel: [Empty];
Coordinated with other nations: [Empty].
Source: GAO analysis of DOD data.
[A] SOCOM headquarters is not developing a pandemic influenza plan.
However, SOCOM planning officials expect that the geographically-based
special operations commands will develop an annex to their geographic
COCOM's plan.
[End of table]
COCOMs Have Established Working Groups to Address Pandemic Influenza:
Each of the geographic COCOMs has established a working group to
address various aspects of pandemic influenza, and each of the
functional COCOMs has either established a working group or is planning
to do so. Medical and operational planning officials from the
geographic COCOMs told us they viewed pandemic influenza planning as
both an operational and force health protection issue and, accordingly,
these groups are generally led by officials in the operations or plans
and policy directorates, the office of the command surgeon, or a
combination of these offices. Officials from across the command, and in
some cases service subcomponents and other federal agencies,
participate regularly or as needed. These working groups oversee
pandemic influenza plan development and work on other aspects of
pandemic influenza preparation. For example, PACOM's working group is
headed by three officials, one each from the operations directorate,
plans and policy directorate, and the Office of the Command Surgeon.
According to a PACOM official, intelligence, logistics, and public
affairs officials regularly attend meetings, and officials from other
directorates and subcomponents attend as needed. The group was
established to develop a pandemic influenza response plan covering
PACOM's geographic area of responsibility based on the November 2005
Joint Staff order to plan for an influenza pandemic.
In addition to its core pandemic influenza planning team, PACOM tasked
two of its service subcomponents to lead operational groups with
responsibilities for pandemic influenza preparation and response in
PACOM's area of responsibility. PACOM designated its Marine
subcomponent, Marine Forces Pacific, to lead PACOM's international
support response during an influenza pandemic, which will be conducted
through a multiservice task force formed to conduct relief operations
during an influenza pandemic.[Footnote 14] The task force may also
conduct noncombatant evacuation operations of Americans living abroad.
PACOM also tasked its Army subcomponent, U.S. Army Pacific, to assist
partner governments and conduct defense support of civil authorities in
PACOM's domestic area of responsibility through a standing task force
that defends PACOM's domestic region from external military threats.
PACOM's domestic area of responsibility, in contrast to the command's
foreign area of responsibility, consists of the state of Hawaii, and
various U.S. territories, possessions, and protectorates, including
Guam, American Samoa, and the Marshall Islands.
Normally in a supporting role, the functional COCOMs were not formally
tasked to plan for pandemic influenza by the November 2005 Joint Staff
planning order. However, each established or intends to establish a
group to prepare for pandemic influenza. For example, JFCOM is in the
process of establishing a pandemic influenza working group. Prior to
establishing the group, JFCOM's operations directorate was leading its
pandemic influenza planning efforts. Once established, JFCOM's working
group will include representatives from select directorates, the
installation where JFCOM's headquarters is located, and the regional
public health emergency officer,[Footnote 15] according to JFCOM
officials.
Additionally, in 2007 NORTHCOM established a working group, called the
Global Pandemic Influenza Working Group, to develop DOD's global plan
for pandemic influenza that applies to all of DOD's COCOMs, military
services, and defense agencies. The working group has met three times
in 2007 and included representatives from the Office of the Secretary
of Defense; the Joint Staff; the geographic COCOMs; three of the four
functional COCOMs; the four military services; two defense agencies--
the Defense Intelligence Agency and the Defense Logistics Agency--and
the Air Force Medical Intelligence Center; and other interagency
partners, including the Departments of State, Health and Human
Services, Homeland Security, and Agriculture.
COCOMs Have Developed Pandemic Influenza Plans for Their Areas of
Responsibility:
At the time of our review, eight of the nine COCOMs had developed or
were developing a plan to prepare for and respond to a potential
pandemic influenza outbreak. Figure 3 illustrates when the COCOMs
started their pandemic influenza planning efforts.
Figure 3: Timeline of COCOMs' Pandemic Influenza Planning Efforts:
[See PDF for image]
Source: GAO analysis of DOD information
Note: SOCOM headquarters is not developing a pandemic influenza plan.
However, SOCOM planning officials expect that the geographically-based
special operations commands will develop an annex to their geographic
COCOMs' plan.
[End of figure]
In November 2005, the Joint Staff requested that the geographic COCOMs
develop or adapt existing pandemic influenza plans to address force
health protection, defense support of civil authorities, and
humanitarian assistance. Two geographic COCOMs, EUCOM and PACOM, began
developing plans before the November 2005 planning order. In August
2005, PACOM issued an instruction on pandemic influenza preparation and
response. Similarly, in August 2005, EUCOM began developing its plan as
a result of media reports of avian influenza cases. Although the Joint
Staff did not request that the functional COCOMs develop plans, three
of the four functional COCOMs are developing plans to preserve their
ability to continue their own operations or to address their support
role during an influenza pandemic. While SOCOM's headquarters was not
developing a pandemic influenza plan, SOCOM planning officials said
they expect each of the geographically-based special operations
commands will develop an annex for their respective geographic COCOMs'
plan; the tasking to develop these plans will come from the geographic
COCOM, rather than SOCOM. For example, PACOM's special operations
component is developing a plan for special operations forces in PACOM's
area of responsibility.
Each of the geographic COCOMs' plans contain phases that indicate
various actions for the COCOMs to take prior to and during a potential
pandemic. DOD generally uses phases in its plans when conducting
complex joint, interagency, or multinational operations to integrate
and synchronize interrelated activities. The Joint Staff required that
the geographic COCOMs' plans take into account the WHO phases for an
influenza pandemic; however, the COCOMs were not required to adopt the
same phases. This allowed the COCOMs to develop their own phasing
structures for their plans and, as a result, the COCOMs plans have
different phasing structures. By definition, an influenza pandemic
would simultaneously affect multiple geographic COCOMs' areas of
responsibility and would, therefore, require unified and cohesive
efforts to respond. According to officials from the Office of the
ASD(HD&ASA), the Joint Staff, and two of the COCOMs, differing phasing
structures may result in the COCOMs' plans having gaps and duplication
of effort among the COCOMs. Using a uniform phasing structure may
increase the likelihood that all COCOMs understand what actions to take
and when to take those actions, resulting in a unified and cohesive
effort. At the time of our review, NORTHCOM, as the lead COCOM for
DOD's planning efforts, was drafting an overarching plan for the
COCOMs' response to an influenza pandemic, which is to include a common
phasing structure for the COCOMs' plans.
The COCOMs' plans include not only actions to respond to an influenza
pandemic, but also actions to prepare for an influenza pandemic.
According to planning officials, each of the geographic COCOMs is
implementing actions from the initial phases of their plans. Planning
officials at four of the five geographic COCOMs told that us that
advance preparation was essential for an effective pandemic response.
COCOMs Have Conducted Exercises for Pandemic Influenza Plans:
To test their pandemic influenza plans, five of the nine COCOMs have
conducted a pandemic influenza-related exercise. Three of the
geographic COCOMs--CENTCOM, EUCOM, and PACOM--and one of the functional
COCOMs--STRATCOM--conducted a pandemic or avian influenza-specific
exercise. For example, EUCOM conducted its Avian Wind exercise in June
2006, which included more than 100 participants representing partner
nations, other federal agencies, and DOD and EUCOM components. The
exercise was designed to identify and enhance the coordination of
actions to plan for, respond to, contain, and mitigate the effects of
avian or pandemic influenza within EUCOM's area of responsibility. The
other three COCOMs held smaller tabletop exercises to familiarize
participants with pandemic influenza in general and the COCOMs' plans
more specifically. Additionally, two of the geographic COCOMs--NORTHCOM
and PACOM--included a pandemic influenza scenario within another
exercise. SOUTHCOM planning and medical officials said they have not
yet conducted a pandemic influenza exercise because they are waiting
for information from the countries in their area of responsibility to
determine the status of pandemic influenza planning and preparedness of
those countries which, in turn, will help SOUTHCOM recommend exercises
to address gaps in those countries' preparedness. Until SOUTHCOM has a
clearer assessment of its partner nations' capabilities, SOUTHCOM
officials do not believe generic pandemic influenza-related exercises
are cost-efficient. In the absence of pandemic influenza-related
exercises, medical and operational planning officials from SOUTHCOM
said the command is coordinating with interagency partners, such as the
Pan American Health Organization and the U.S. Agency for International
Development, to gather information on other countries' capabilities and
planning efforts. Although SOUTHCOM plans to conduct its own regional
tabletop exercise later in fiscal year 2007, SOUTHCOM officials said
the command will not (and cannot) get ahead of the Department of State
as the lead federal agent--and other interagency partners--in such
activities. Each of the geographic COCOMs and three of the four
functional COCOMs are planning to conduct pandemic influenza-specific
exercises or include pandemic influenza scenarios in future exercises.
For example, STRATCOM plans to conduct three tabletop exercises--an
internal exercise for STRATCOM's staff; an exercise with the
installation where STRATCOM's headquarters is located (Offutt Air Force
Base, Nebraska); and an exercise with STRATCOM's staff, the
installation, and the civilian community--to test STRATCOM's pandemic
influenza plan to continue its own operations.
Officials from the five COCOMs that have held exercises said they
identified some lessons as a result of their exercises and are starting
to take steps to address these lessons. Some of these lessons were
general and related to overall planning efforts. For example, in March
2006, CENTCOM conducted a tabletop exercise to familiarize participants
with the command's pandemic influenza plan. The results of the exercise
facilitated establishing an operational planning team to continue to
address pandemic influenza efforts, according to CENTCOM's lead
planning official. Similarly, an official responsible for planning
PACOM's exercises said the command included avian influenza in one
scenario in its Cobra Gold exercise in May 2006, a regularly scheduled
multinational exercise hosted by Thailand. In the exercise, PACOM, the
Royal Thai Army, and the Singapore Army planned for implications and
conducted operations supporting humanitarian assistance in an area
where H5N1 avian influenza was a factor. According to a planning
official, PACOM determined that the command needs to hold a separate
pandemic influenza exercise to effectively test its pandemic influenza
plan. However, an official responsible for planning PACOM's exercises
said it has been a challenge to meet another exercise requirement
without additional resources, including personnel and funding.
Similarly, U.S. Forces Korea planning officials said the command has
not held a pandemic influenza-specific exercise or included a pandemic
influenza scenario in any war-planning exercises because of the time
required and lack of funding for such a scenario. Influenza pandemic
exercises have not been a priority because U.S. Forces Korea has been
focused on events involving North Korea. According to a representative
from one of the U.S. Army garrisons in South Korea, the key lesson
learned from a tabletop exercise was that they are "very unprepared"
for an influenza pandemic. Lessons learned from other exercises
pertained to more specific aspects of plans. For example, officials
involved in EUCOM's Avian Wind exercise identified the need to update
the command's continuity of operations plan to increase the likelihood
that critical missions, essential services, and functions could
continue during an influenza pandemic. As a result, EUCOM planning
officials report that the command plans to update its continuity of
operations plan in spring 2007 to include pandemic influenza.
COCOMs Have Started to Provide Information to Personnel about Pandemic
Influenza:
Five of the nine COCOMs--EUCOM, NORTHCOM, PACOM, SOUTHCOM, and
STRATCOM--have started to provide information to their personnel,
including military and civilian personnel, contractors, dependents, and
beneficiaries, about a potential influenza pandemic. COCOMs have used
various strategies to inform personnel about pandemic influenza,
including using various media outlets, training programs, and outreach
events.
Each of the COCOMs that have started to provide information to their
personnel used radio or television commercials, news articles,
briefings, or a combination of these means, to inform personnel about
avian and pandemic influenza. Additionally, three of the COCOMs had a
page on their publicly available Web sites that included some avian and
pandemic influenza information and links to other Web sites, such as
the federal government's pandemic influenza Web site,
www.pandemicflu.gov.
Three COCOMs--EUCOM, PACOM, and STRATCOM--offered training courses to
inform personnel about pandemic influenza. Both EUCOM and PACOM offered
training for public health emergency officers. In May 2006 and
September 2006, EUCOM's training for its public health emergency
officers included general information about pandemic and avian
influenza as well as strategies about how to communicate pandemic
influenza-related information to beneficiaries. According to STRATCOM
officials, in October 2006, STRATCOM required military and civilian
personnel to complete a computer-based training module about pandemic
and avian influenza that included information on force health
protection measures, among other issues.
Additionally, three COCOMs--PACOM, STRATCOM, and EUCOM--have used
outreach programs to inform personnel, including military and civilian
personnel, contractors, dependents, and beneficiaries, about pandemic
influenza. A group of military medical professionals at PACOM conducted
a series of public outreach events at military exchanges in Hawaii that
combined providing seasonal flu vaccinations to military personnel,
dependents, and beneficiaries with educating personnel by distributing
information about general preventive health measures, as well as
pandemic influenza. For example, the PACOM officials distributed
pamphlets on cough etiquette, how to prepare for an influenza pandemic,
and a list of items to keep on hand in an emergency kit. Figure 4 shows
one of PACOM's military medical professionals sharing information with
dependents and beneficiaries at a November 2006 event at the Navy
Exchange in Honolulu, Hawaii. Similarly, STRATCOM held an outreach
event, called "Pandemic Influenza Focus Day," in November 2006 for its
military and civilian personnel and contractors. During the Focus Day,
each directorate or office met to discuss the impact that a 40 percent
absenteeism rate due to personnel being sick, caring for someone who
was sick, or afraid to come to work, would have on the individual
directorate or office.[Footnote 16] Additionally, in March 2006, EUCOM
directed service subcomponents that had not already done so to hold
installation-level meetings to inform military and civilian personnel,
contractors, dependents, and beneficiaries about the threat of avian
influenza and related preventive measures.
Figure 4: Official Provides Information about Pandemic Influenza at
PACOM's Outreach Event:
[See PDF for image]
Source: GAO
[End of figure]
COCOMs Have Coordinated with Other Nations:
Each of the geographic COCOMs has started to work or plans to work with
nations in its area of responsibility to raise awareness about and
assess capabilities for responding to avian and pandemic influenza.
COCOMs undertook some of these outreach efforts as a result of an
action assigned to DOD as a lead agency in the national implementation
plan to conduct assessments of avian and pandemic influenza
preparedness and response plans of the militaries in partner nations
(action 4.1.1.3). For example, CENTCOM's lead planning official
reported that CENTCOM performed assessments and identified gaps for
Afghanistan's pandemic influenza preparedness and response and has
obtained funding for projects with the Afghanistan National Army and
the Ministries of Public Health, Agriculture, and Higher Education. The
CENTCOM official also noted, among other outreach efforts in the
region, a meeting with a military medical delegation from Pakistan to
discuss assessing the Pakistani military's pandemic influenza
preparedness and response efforts. Officials involved in EUCOM's
pandemic influenza planning and humanitarian assistance programs
reported that EUCOM plans to complete the assessments through its
regular coordination efforts with militaries in partner nations. While
EUCOM obtained $1 million from the Combatant Commander Initiative Fund
to complete actions assigned to DOD as a lead agency in the national
implementation plan,[Footnote 17] EUCOM officials cited resources,
including funding, as a challenge to completing these assessments by
the November 2007 deadline.
COCOMs also have started to take or plan to take other actions to work
with other nations related to pandemic influenza. For example, SOUTHCOM
plans to hold regional conferences focused on pandemic influenza to
help educate partner nations, assess the preparedness of nations in the
region, and identify appropriate contacts within the nations. SOUTHCOM
planning and medical officials said they have two conferences
tentatively planned, but noted that the number of conferences they can
hold will be determined by the availability of funding. According to
these officials, the conferences will address a variety of topics
related to pandemic influenza, including developing plans and
interagency collaboration. Moreover, officials from PACOM, Marine
Forces Pacific, U.S. Forces Japan, and U.S. Forces Korea participated
in a multilateral workshop with officials from Japan and South Korea to
discuss the potential threat of a pandemic influenza in the Asia-
Pacific region. Participants shared information about national
strategies and military response plans and discussed ways to leverage
existing partnerships, enhance interoperability, and integrate planning
efforts to minimize the health and economic impact of an influenza
pandemic.
COCOMs Face Three Management Challenges as They Continue to Prepare for
an Influenza Pandemic:
While COCOMs have taken numerous actions to prepare for an influenza
pandemic, we identified three management challenges that the COCOMs
face as they continue their planning and preparedness efforts. First,
the roles, responsibilities, and authorities of key organizations
involved in the COCOMs' planning and preparedness efforts relative to
other lead and supporting organizations remained unclear. As a result,
the unity and cohesiveness of DOD's pandemic influenza preparation
could be impaired and the potential remains for confusion among
officials and gaps and duplication in actions taken by the COCOMs
relative to the military services and other DOD organizations in
implementing tasks, such as the actions assigned to DOD as a lead
agency in the national implementation plan. Second, we identified a
disconnect between the COCOMs' planning and preparedness activities and
resources, including funding and personnel, to complete those
activities. The continued disconnect between activities and resources
may limit the COCOMs' ability to effectively prepare for and respond to
an influenza pandemic. Third, we identified some factors that are
beyond the COCOMs' control--such as limited detailed guidance from
other federal agencies on the support expected from DOD, lack of
control over DOD's antiviral stockpile, limited information on
decisions that other nations may make during an influenza pandemic,
reliance on civilian medical providers for medical care, and reliance
on military services for medical materiel--that they have not yet fully
planned how to mitigate. While we recognize the difficulty in planning
for an influenza pandemic, not yet developing options to mitigate the
effects of such factors may place at risk the COCOM commanders' ability
to protect their personnel--including military and civilian personnel,
contractors, dependents, and beneficiaries--or to perform their
missions during an influenza pandemic.
Roles, Responsibilities, and Authorities of Key Organizations Relative
to Others Are Not Fully and Clearly Defined:
The roles, responsibilities, and authorities of key organizations
involved in DOD's pandemic influenza planning and preparedness efforts
relative to other organizations leading and supporting the department's
pandemic influenza planning efforts-- including NORTHCOM as the lead
for DOD's planning and the individual COCOMs--remained unclear because
of the continued lack of sufficiently detailed guidance from the
Secretary of Defense or his designee. We have previously reported that
in preparing for and responding to any type of disaster, leadership
roles and responsibilities must be clearly defined, effectively
communicated, and well understood to facilitate rapid and effective
decision making.[Footnote 18] As a result of not yet issuing guidance
fully and clearly defining the roles, responsibilities, authorities,
and relationships of key organizations, the unity and cohesiveness of
DOD's pandemic influenza preparation could be impaired, and the
potential remains for confusion among COCOM officials and gaps or
duplication in actions taken by the COCOMs relative to the military
services and other DOD organizations.
In our September 2006 report, we identified the absence of clear and
fully defined guidance on roles, responsibilities, and lines of
authority for the organizations involved in DOD's pandemic influenza
preparedness efforts as a potential hindrance to DOD's ability to
effectively prepare for an influenza pandemic, and recommended that DOD
take actions to address this issue,[Footnote 19] but DOD had not yet
done so. Officials from the Office of the ASD(HD&ASA), the Office of
the ASD for Health Affairs, and the Joint Staff responded to the
recommendations in our September 2006 report by stating that DOD's
implementation plan for pandemic influenza clearly establishes the
roles and responsibilities for organizations throughout DOD. In its
implementation plan, DOD established offices of primary responsibility
for policy oversight of various tasks and outlined medical support
tasks assigned to various organizations, but we found that the plan
stopped short of fully and clearly identifying roles, responsibilities,
and lines of authority for all key organizations, including the COCOMs.
Since planning has occurred concurrently within DOD at various levels
from the Office of the Secretary of Defense to installations, a more
extensive delineation of roles, responsibilities, and lines of
authority could lead to a more efficient and effective effort.
DOD has outlined NORTHCOM's roles and responsibilities as the lead
COCOM for the department's pandemic influenza planning efforts. In
August 2006, the Secretary of Defense named NORTHCOM the lead COCOM for
directing, planning, and synchronizing DOD's global response to
pandemic influenza, or the "global synchronizer" for DOD's pandemic
influenza planning. In April 2007, the Joint Staff issued a planning
order that, among other things, outlined NORTHCOM's roles and
responsibilities as global synchronizer, including:
* serving as a conduit between the Joint Staff or Office of the
Secretary of Defense and the COCOMs, military services, and defense
agencies on pandemic influenza-related issues;
*assessing and advocating for resources for the COCOMs, military
services, and defense agencies; and
*leading planning efforts for the COCOMs, military services, and
defense agencies, but not the execution of those plans in the other
COCOMs' areas of responsibility.
While DOD has outlined NORTHCOM's roles and responsibilities as the
global synchronizer, the command's roles, responsibilities, and
authorities relative to the lead offices for DOD's overall pandemic
influenza planning efforts, as well as the relationships between the
organizations, were not yet fully and clearly defined. The ASD(HD&ASA)
is the lead, in coordination with the ASD for Health Affairs, for DOD's
pandemic influenza planning and preparedness efforts departmentwide,
and the Joint Staff also plays a key role in DOD's pandemic influenza
planning. However, neither the Secretary of Defense nor his designee
had yet issued guidance fully and clearly stating how NORTHCOM's roles
and responsibilities as the lead for the COCOMs' planning efforts
differed from the roles and responsibilities of the other lead offices
for pandemic influenza preparedness efforts, including the Joint Staff,
which led to varying expectations among some COCOM officials. For
example, COCOM officials had different expectations about whether
NORTHCOM would provide guidance to the COCOMs. Planning officials from
two geographic COCOMs noted that the Joint Staff, not NORTHCOM, has the
primary authority to provide guidance to the COCOMs. However, planning
officials from at least three COCOMs were expecting NORTHCOM to provide
guidance on key issues, such as quarantine, social distancing,
treatment of DOD beneficiaries, and troop rotation. Additionally, there
was confusion among the COCOMs on which organization was responsible
for overseeing interagency coordination. Planning officials at one
COCOM, as well as officials from the Office of the ASD(HD&ASA), the
Office of the ASD for Health Affairs, and the Joint Staff, said offices
within the Office of the Secretary of Defense and the Joint Staff would
remain the points of contact for the actions assigned to DOD in the
national implementation plan and would also remain the primary contacts
for coordinating with other federal government agencies. However, a
planning official from another geographic COCOM said that the global
synchronizer role meant that NORTHCOM would coordinate with other
federal government agencies for pandemic influenza planning. At the
time of our review, officials leading NORTHCOM's planning and
preparedness efforts acknowledged that the command's roles and
responsibilities relative to the Joint Staff and offices within the
Office of the Secretary of Defense were not well-defined, especially
concerning direct coordination and sharing information with the other
federal agencies, and that the command needed further guidance from the
Office of the Secretary of Defense and the Joint Staff to more clearly
establish its roles and responsibilities.
Similarly, the roles, responsibilities, and authorities of the
individual COCOMs for DOD's pandemic influenza planning and
preparedness efforts were not yet fully and clearly defined. While
there is guidance--such as the Unified Command Plan and 10 U.S.C. §
164--that describes the overall roles, responsibilities, and
authorities of the COCOMs, we found that the COCOMs' roles,
responsibilities, and authorities related to DOD's pandemic influenza
planning and preparedness efforts were unclear. For example, medical
and operational planning officials from three COCOMs said it was not
clear to them which of the 31 actions assigned to DOD as a lead agency
in the national implementation plan the COCOMs were to help complete.
Officials from two of these COCOMs said that officials within the
Office of the Secretary of Defense and the Joint Staff had not yet
clearly stated which actions assigned to DOD in the national
implementation plan should be implemented by COCOMs and which by the
military services. Officials from the Office of the ASD(HD&ASA) and the
Joint Staff said the COCOMs were responsible for implementing few of
the actions assigned to DOD as a lead agency in the national
implementation plan. However, in the absence of clear guidance, each of
the COCOMs identified the actions they believed they are partly
responsible for implementing. COCOM officials told us they determined
they were partly responsible for between 12 and 18 of the 31 actions
for which DOD is a lead agency, as shown in table 2. We identified some
inconsistency in which actions the geographic COCOMs saw as their
responsibility to fulfill.
Table 2: COCOM Perceptions of Responsibility for Actions Assigned to
DOD:
Action number: 4.1.1.3;
Action assigned to DOD: Conduct military-to- military assistance
planning;
CENTCOM: X;
EUCOM: X;
NORTHCOM: X;
PACOM: X;
SOUTHCOM: X.
Action number: 4.1.2.6;
Action assigned to DOD: Priority country military-to-military infection
control training;
CENTCOM: X;
EUCOM: X;
NORTHCOM: X;
PACOM: X;
SOUTHCOM: X.
Action number: 4.1.8.4;
Action assigned to DOD: Open source information sharing;
CENTCOM: [Empty]; EUCOM: X;
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 4.2.2.5;
Action assigned to DOD: Inpatient and outpatient disease surveillance;
CENTCOM: X;
EUCOM: X;
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: X.
Action number: 4.2.2.6;
Action assigned to DOD: Monitoring health of military forces worldwide;
CENTCOM: X;
EUCOM: X;
NORTHCOM: [Empty];
PACOM: X;
SOUTHCOM: [Empty].
Action number: 4.2.2.7;
Action assigned to DOD: Assist with influenza surveillance in host
nations;
CENTCOM: X;
EUCOM: X;
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: X.
Action number: 4.2.3.8;
Action assigned to DOD: Develop/enhance DOD network of overseas
infrastructure[A];
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 4.2.3.9;
Action assigned to DOD: Refinement of DOD laboratory methods;
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: [Empty];
PACOM: X;
SOUTHCOM: X.
Action number: 4.2.3.10;
Action assigned to DOD: Assess foreign country military laboratory
capacity;
CENTCOM: X;
EUCOM: X;
NORTHCOM: X;
PACOM: X;
SOUTHCOM: X.
Action number: 4.2.4.2;
Action assigned to DOD: COCOM public health reports for area personnel;
CENTCOM: X;
EUCOM: X;
NORTHCOM: X;
PACOM: X;
SOUTHCOM: X.
Action number: 4.3.2.2;
Action assigned to DOD: Identify DOD facilities to serve as points of
entry from outbreak countries;
CENTCOM: X;
EUCOM: X;
NORTHCOM: X;
PACOM: [Empty];
SOUTHCOM: X.
Action number: 5.1.1.5;
Action assigned to DOD: Assessment of military support for
transportation and borders;
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: X;
PACOM: X;
SOUTHCOM: X.
Action number: 5.3.4.8;
Action assigned to DOD: Strategic military deployment use of airports
and seaports;
CENTCOM: X;
EUCOM: X;
NORTHCOM: X;
PACOM: [Empty];
SOUTHCOM: X.
Action number: 5.3.5.5;
Action assigned to DOD: Monitor and report on military assets requested
for border protection;
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: X;
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 6.1.6.3;
Action assigned to DOD: Conduct medical materiel requirements gap
analysis;
CENTCOM: X;
EUCOM: X;
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: X.
Action number: 6.1.6.4;
Action assigned to DOD: Maintain antiviral and vaccine stockpiles[A];
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 6.1.7.4;
Action assigned to DOD: Establish stockpiles of vaccine against H5N1[A];
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 6.1.9.3;
Action assigned to DOD: Procure 2.4 million antiviral medications[A];
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 6.1.13.8;
Action assigned to DOD: Supply military units/ bases with influenza
medication;
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: X.
Action number: 6.2.2.9;
Action assigned to DOD: Enhance public health response capabilities;
CENTCOM: X;
EUCOM: X;
NORTHCOM: [Empty];
PACOM: X;
SOUTHCOM: [Empty].
Action number: 6.2.3.4;
Action assigned to DOD: Access to improved rapid diagnostic tests;
CENTCOM: X;
EUCOM: X;
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 6.2.4.3;
Action assigned to DOD: Provide health statistics on influenza-like
illnesses;
CENTCOM: [Empty];
EUCOM: X;
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 6.3.2.4;
Action assigned to DOD: DOD guidance to personnel on protective
measures;
CENTCOM: X;
EUCOM: X;
NORTHCOM: X;
PACOM: X;
SOUTHCOM: X.
Action number: 6.3.2.5;
Action assigned to DOD: Implement infection control campaigns;
CENTCOM: X;
EUCOM: [Empty];
NORTHCOM: X;
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 6.3.4.7;
Action assigned to DOD: Enhance influenza surveillance reporting
techniques;
CENTCOM: X;
EUCOM: X;
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 6.3.7.2;
Action assigned to DOD: Be prepared to augment state/local government
medical response;
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: X;
PACOM: X;
SOUTHCOM: [Empty].
Action number: 6.3.7.5;
Action assigned to DOD: Reserve medical personnel mobilization;
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 6.3.8.2;
Action assigned to DOD: Update risk communication material;
CENTCOM: [Empty];
EUCOM: X;
NORTHCOM: [Empty];
PACOM: X;
SOUTHCOM: [Empty].
Action number: 8.1.2.5;
Action assigned to DOD: National Guard training for state law
enforcement[A];
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: [Empty];
PACOM: [Empty];
SOUTHCOM: [Empty].
Action number: 8.1.2.6;
Action assigned to DOD: Requests for assistance from states/governors;
CENTCOM: [Empty];
EUCOM: [Empty];
NORTHCOM: [Empty];
PACOM: X;
SOUTHCOM: [Empty].
Action number: 8.3.2.1;
Action assigned to DOD: Plans for quarantine enforcement;
CENTCOM: [Empty];
EUCOM: X;
NORTHCOM: X;
PACOM: X;
SOUTHCOM: [Empty].
Total;
CENTCOM: 15;
EUCOM: 18;
NORTHCOM: 12;
PACOM: 13;
SOUTHCOM: 13.
Source: GAO analysis of DOD data.
* None of the COCOMs indicated that they were responsible for
implementing six of the actions assigned to DOD in the national
implementation plan. Therefore, these rows are blank.
[End of table]
COCOM officials' varying interpretations of which actions applied to
them could lead to gaps in the completion of actions assigned to DOD or
duplications in effort. For example, operational and medical planning
officials from the Joint Staff, the Office of the ASD(HD&ASA), and the
Office of the ASD for Health Affairs told us that there were no
additional force health protection actions assigned to COCOMs, but
COCOM medical and planning officials told us they shared responsibility
for some of the force health actions, including actions relating to
monitoring force health (action 4.2.2.6), analyzing medical materiel
needs (action 6.1.6.3), and implementing infection control campaigns
(action 6.3.2.5). Officials from the Joint Staff and the Office of the
ASD(HD&ASA) told us this confusion was evident in the collection of
information on funding needs from COCOMs, as the COCOMs identified
funding needs for actions these officials thought the COCOMs were not
intended to fulfill.
In addition, we identified that there was little guidance on what
constituted fulfillment of the actions, some of which were open to
interpretation and potentially were quite broad. For example, one
action, which the Joint Staff issued to the geographic COCOMs, calls
for DOD to assess the avian and pandemic influenza response plans of
partner militaries, develop solutions for national and regional gaps,
and develop and execute military-to-military influenza exercises to
validate such plans (action 4.1.1.3), by November 2007. The wide scope
for interpretation of the actions meant that COCOMs could expend
unnecessary effort or fail to complete actions intended for them.
Without fully and clearly identifying the roles, responsibilities, and
authorities of the COCOMs, including a clear delineation of which
actions apply to which organizations and what constitutes fulfillment
of an action, DOD's preparation for an influenza pandemic risks gaps in
efforts by failing to execute some actions by assuming that an action
will be fulfilled by other organizations; duplicating efforts, as
COCOMs may undertake actions that other DOD organizations are meant to
complete; or both.
Furthermore, the roles, responsibilities, and authorities of COCOMs
relative to the military services for DOD's pandemic influenza planning
and preparedness efforts were also not yet fully and clearly defined.
The memorandum that names NORTHCOM the lead for directing, planning,
and synchronizing DOD's global response to pandemic influenza is not
limited to the efforts of the COCOMs; however, planning officials from
one COCOM said it was unclear what authority NORTHCOM had over the
military services. The April 2007 planning order directs the military
services to coordinate with NORTHCOM to ensure that the services'
pandemic influenza plans are synchronized with DOD's global pandemic
influenza plan but does not define what this coordination entails. In
addition to the need for more information on which actions the COCOMs
were to complete compared to the military services discussed above,
COCOM medical and planning officials sought clarification on the
differences in the roles and responsibilities of the COCOMs and
military services in implementing force health protection actions and
moving medical assets within the area of responsibility. The November
2005 Joint Staff planning order tasked COCOMs to include force health
protection in their plans for pandemic influenza. Planning officials
from two of the geographic COCOMs said that, in general, COCOMs set the
requirements for force health protection in their areas of
responsibility and the military services are responsible for ensuring
that their forces meet these requirements. However, medical and
planning officials from one COCOM viewed the November 2005 Joint Staff
planning order as assigning force health protection activities to the
COCOMs and noted that pandemic influenza is the only area where the
COCOMs are responsible for medical issues. Moreover, medical and
planning officials from one of the COCOM's service subcomponents noted
that because the COCOM's plan includes a "shaping" phase, which
currently is being implemented, the COCOMs have a greater
responsibility for force health protection than in other operations. A
medical official from one COCOM noted that COCOMs can identify many of
the things needed to prepare for and respond to an influenza pandemic,
but the COCOMs lack the day-to-day authority over installations and
resources to direct that these measures be taken during the initial
phases of the COCOM's plan because force health protection typically is
the responsibility of the military services. Similarly, planning
officials at two geographic COCOMs reported concerns that they would
not have the authority in a pandemic to move medical assets, such as
antivirals, from one base in their area of responsibility controlled by
one military service to another base controlled by a different service.
An official from the Office of the ASD for Health Affairs confirmed
that this is an issue, particularly within the United States, and noted
that the military services and COCOMs will have to resolve this issue
on their own because the Office of the ASD for Health Affairs is not
part of the COCOMs' or military services' chains-of-command.
The unity and cohesiveness of DOD's pandemic influenza planning,
preparation, and response efforts could be hindered by the continued
lack of fully and clearly defined roles, responsibilities, authorities,
and relationships of organizations throughout DOD involved in these
efforts. While the April 2007 planning order outlines NORTHCOM's roles
and responsibilities, the lack of clarity of the roles,
responsibilities, and authorities of key organizations involved in the
COCOMs' planning and preparedness efforts relative to other lead and
supporting organizations has created the potential for confusion, gaps,
and overlaps in areas such as the actions assigned to DOD in the
national implementation plan as well as force health protection
measures for DOD's personnel. Without more fully and clearly defined
roles and responsibilities, various organizations could fail to carry
out certain actions or, alternatively, may perform actions that other
organizations were to complete. Additionally, it may be difficult for
DOD to accurately capture funding requirements without a clear
delineation of which actions are to be executed by which organizations,
as well as the scope of the actions. Finally, COCOM planning and
response could be less effective if commanders do not have a clear
sense of the assets under their control, such as medical materiel at
service-controlled installations.
DOD Has Not Identified Resources to Complete Planning and Preparedness
Activities:
We identified a disconnect between the COCOMs' planning and
preparedness activities and resources, including funding and personnel,
to complete those activities. This disconnect is, in part, because DOD
guidance, including DOD's implementation plan for pandemic influenza
and the Joint Staff planning order that directed the COCOMs to plan,
did not identify the resources required to complete these activities.
We have previously reported that information on required resources is
critical for making sound analyses of how to pursue goals.[Footnote 20]
Without realistic information on required resources, decision makers
cannot determine whether a strategy to achieve those goals is realistic
and cost-effective or make trade-offs against other funding priorities.
In September 2006, we reported that DOD had not yet identified an
appropriate funding mechanism or requested funding tied to its
departmentwide goals, which could impair the department's overall
ability to prepare for a potential pandemic, and recommended that DOD
take actions to address this issue.[Footnote 21] DOD generally
concurred with our recommendation, but had not yet taken actions to
address this recommendation. The continued lack of a link between the
COCOMs' planning and preparedness activities and the resources required
for them may limit the COCOMs' ability to effectively prepare for and
respond to an influenza pandemic.
DOD did not request dedicated funding for its pandemic influenza
preparedness activities in its fiscal year 2007 or fiscal year 2008
budget requests because, according to the Principal Deputy to the
ASD(HD&ASA), several baseline plans, including the national
implementation plan, DOD's implementation plan, and the geographic
COCOMs' plans, needed to be drafted before DOD could assess its
potential preparedness costs. Officials from the Office of the
ASD(HD&ASA) and the Office of the ASD for Health Affairs were aware of
the disconnect between the COCOMs' planning and preparedness activities
and resources to accomplish these activities. The officials said that
when the Homeland Security Council originally developed the national
implementation plan, the officials expected to receive supplemental
funding to complete the actions assigned to DOD. However, in the
absence of sustained supplemental funding, the officials said they are
struggling to find programs from which to divert resources to fund the
department's planning and preparedness activities. In December 2005,
DOD received $130 million in supplemental appropriations for pandemic
influenza; $120 million was for expenses, including health-related
items for its own personnel, and $10 million was to provide equipment
and assistance to partner nations.[Footnote 22] However, as the
Congressional Research Service reported, tracking federal funds for
influenza preparedness is difficult because funds designated for
pandemic influenza preparedness do not reflect the sum of all relevant
activities, including developing the department's pandemic influenza
plan.[Footnote 23] The COCOMs have a certain amount of discretion over
their operations and maintenance budgets to fund pandemic influenza-
related activities. Although COCOM officials have started to identify
funding requirements through multiple Joint Staff inquiries regarding
COCOM funding needs, planning, medical, and budget officials from the
geographic COCOMs said there is still not an accurate assessment of
actual funding needs and DOD has not yet requested funding for the
department's planning and preparedness activities. An official from the
Office of the ASD(HD&ASA) said obtaining funding to fully establish
NORTHCOM as the global synchronizer for the department's efforts is the
office's top priority. After NORTHCOM establishes its global
synchronizer role, the official said one of NORTHCOM's responsibilities
will be to assist the Joint Staff in determining how much funding is
required for DOD's pandemic influenza planning and preparedness
activities.
Without resources identified for planning and preparedness activities,
COCOMs have reallocated resources from other sources to undertake these
activities. For example, budget officials at EUCOM said, in the absence
of dedicated funding for pandemic influenza-related activities, EUCOM
spent about $145,000 of its Operations and Maintenance funding in
fiscal year 2006 for travel to pandemic influenza-related conferences
and for its Avian Wind exercise. COCOMs have also diverted planners
from other areas to develop pandemic influenza plans. Planning
officials from four of the five geographic COCOMs and four of the
subcomponents we met with said pandemic influenza planning was one of
many responsibilities for the personnel involved in their pandemic
influenza planning and preparedness efforts, and often their other
responsibilities were a higher priority. For example, planning
officials from U.S. Forces Korea stated that they cannot dedicate the
level of effort that pandemic influenza planning requires because of
other more immediate priorities on the Korean peninsula. Similarly,
members of CENTCOM's pandemic influenza planning team said they were
distracted by a variety of other tasks calling for immediate action,
many of which are related to the wars in Iraq and Afghanistan, and
devoted a small percentage of their time to pandemic influenza; only
the lead planner in the team was able to devote a significant
percentage of time to pandemic influenza planning.
As a result of the lack of identified resources for DOD's pandemic
influenza planning and preparedness activities, planning officials from
at least three COCOMs said that they will likely be unable to complete
some important activities. For example, although the Joint Staff
planning order tasked geographic COCOMs to exercise their pandemic
influenza plans at least once a year, officials responsible for
CENTCOM's planning and PACOM's planning and exercises told us they need
additional resources to conduct these exercises. While EUCOM has
conducted an exercise, planning officials told us that they have had to
reconsider future exercises because of the lack of resources.
Additionally, officials from each of the COCOMs said they lack
resources to complete some of the actions in the national
implementation plan. For example, while the Joint Staff tasked all of
the geographic COCOMs to assess the avian and pandemic influenza
response plans of partner militaries, develop solutions for national
and regional gaps, and develop and execute military-to-military
influenza exercises to validate such plans (action 4.1.1.3), planning
and medical budget officials from each of the geographic COCOMs said
that they may be unable to complete this action by the November 2007
deadline because of the lack of resources, including funding.
COCOMs Have Not Yet Developed Options to Mitigate the Effects of
Factors beyond Their Control:
We identified factors that are beyond the COCOMs' control--such as
limited detailed guidance from other federal agencies on the support
expected from DOD, lack of control over DOD's antiviral stockpile,
limited information on decisions that other nations may make during an
influenza pandemic, reliance on civilian medical providers for medical
care, and reliance on military services for medical materiel--that they
have not yet fully planned how to mitigate. While we recognize the
difficulty of planning for an influenza pandemic, not yet developing
options to mitigate the effects of such factors may limit the COCOM
commanders' ability to protect their personnel--including military and
civilian personnel, contractors, dependents, and beneficiaries--or to
perform their missions during an influenza pandemic.
We have recommended a comprehensive risk-management approach as a
framework for decision making.[Footnote 24] Risk involves three
elements: (1) threat, which is the probability that a specific event
will occur; (2) the vulnerability of people and specific assets to that
particular event; and (3) the adverse effects that would result from
the particular event should it occur. We define risk management as a
continuous process of assessing risks; taking actions to reduce, where
possible, the potential that an adverse event will occur; reducing
vulnerabilities as appropriate; and putting steps in place to reduce
the effects of any event that does occur. Since it is not possible for
the COCOMs to reduce the potential for an influenza pandemic, it is
important they reduce their vulnerabilities and put in place steps to
mitigate the effects of a potential pandemic.
COCOMs Have Not Yet Developed Options to Mitigate the Effects of
Limited Detailed Guidance from Other Federal Agencies:
Planning officials from four of the five COCOMs told us they had
received limited detailed guidance from other federal agencies on what
support they might be asked to provide during an influenza pandemic or
information that could help the COCOMs estimate such potential support.
This is one factor that has hindered their ability to plan to provide
support to other federal agencies domestically and abroad during an
influenza pandemic. DOD was designated as a supporting agency for
pandemic influenza response in the national implementation plan. After
Hurricane Katrina, we reported that the military has significant and
sometimes unique capabilities, but additional actions are needed to
ensure that its contributions are clearly understood and well planned
and integrated.[Footnote 25] Additionally, we reported that many
challenges faced in the response to Hurricane Katrina point to the need
for plans that, among other things, identify capabilities that could be
available and provided by the military. Planning officials from each of
the geographic COCOMs said they anticipate that, during an influenza
pandemic, the COCOM will provide support domestically and abroad as
requested by other federal agencies and approved by the Secretary of
Defense. However, planning officials from four of the five geographic
COCOMs said they had not yet received detailed information from the
Department of State on what assistance other nations may request from
the United States. Without this information, the officials said they
cannot effectively plan to provide support. Department of State
officials told us they would not know what specific kinds of support
other nations may need until an influenza pandemic occurred, but they
had developed a list of priority countries for the U.S. government's
pandemic influenza response. Additionally, Department of State
officials said they had started to assess what kinds of support may be
needed for embassies and they have developed a request for information
about the level of assistance DOD may be able to provide at a specific
list of posts deemed most vulnerable from a medical and security
standpoint should an influenza pandemic emerge. Department of State
officials expected that the request for information would be sent to
DOD by the end of June 2007. At least one COCOM has taken steps to
mitigate the effects of limited information, pending further
information from the Department of State. PACOM established
multiservice teams to work with nations, territories, possessions, and
protectorates in its area of responsibility to identify potential needs
during an influenza pandemic. For example, in September 2006 about 15
PACOM officials went to Malaysia to provide an avian and pandemic
influenza "train the trainer" workshop, obtain information on the
country's pandemic influenza planning efforts, and identify areas of
mutual collaboration to increase the likelihood of a coordinated
response to the current threat of avian influenza and a potential
influenza pandemic. Planning officials from three COCOMs and two
service subcomponents that we met with said planning to provide support
at the last minute could lead to a less effective and less efficient
use of resources. While identifying what capabilities may be needed and
available at an indefinite point in the future is difficult, taking
these steps now could allow the COCOMs to be better prepared to provide
support to other federal agencies domestically and abroad during an
influenza pandemic.
COCOMs Have Not Yet Developed Options to Mitigate the Effects of a Lack
of Control over DOD's Antiviral Stockpile:
COCOM medical and planning officials have expressed concern about how
they would gain access to and use DOD's stockpile of antivirals. These
officials reported that their lack of control over DOD's stockpile of
antivirals has limited their ability to plan to use this resource. The
ASD for Health Affairs procured antivirals and prepositioned DOD's
antiviral stockpile in the continental United States, Europe, and the
Far East. The ASD for Health Affairs retained the authority to release
the antivirals to allow more flexibility to direct these limited
resources where they are needed the most, according to an official in
the Office of the ASD for Health Affairs. However, according to
planning and medical officials at three of the COCOMs, the absence of
information about these assets has made it more difficult to plan for
their use because the COCOM officials did not know when they would
receive the antivirals or how many doses they would receive. For
example, EUCOM planning and medical officials said that during a
NORTHCOM exercise in 2006, it took 96 hours for the ASD for Health
Affairs to authorize the release of antivirals. The EUCOM officials
expressed concern that a lengthy release process could impact the
effectiveness of antivirals, as they are most effective if given within
48 hours of showing influenza-like symptoms. According to the
officials, the lack of information on when the COCOMs might receive
antivirals and how many antivirals they may receive limits the COCOMs'
ability to plan for how they will use these resources and what steps
they may need to take to transport, store, and secure these resources
after the ASD for Health Affairs releases the stockpile. To help
address this issue, the Office of the ASD for Health Affairs
distributed about 470,000 treatment courses of an antiviral to military
treatment facilities, which can be administered as determined by the
facility's commander. Additionally, at least two service subcomponents
purchased their own supply of antivirals to be used for critical
personnel during an influenza pandemic. However, by not yet taking
steps to mitigate the effect of not having sufficient information to
plan to use antivirals in their areas of responsibility, COCOMs may not
be prepared to effectively and efficiently use these resources or
protect their personnel.
COCOMs Have Not Yet Developed Options to Mitigate the Effects of
Limited Information on Other Nations' Decisions:
Planning officials at four of the geographic COCOMs and one of the
functional COCOMs mentioned the need for information on decisions other
nations may make during an influenza pandemic, such as closing borders
or restricting transportation into and out of the country, as a factor
that has hindered their ability to plan to continue ongoing missions
during an influenza pandemic. For example, currently most
servicemembers injured in Iraq and Afghanistan, in the CENTCOM area of
responsibility, travel to Germany for essential medical care. EUCOM
planning officials noted that Germany has reserved the right to close
off access to Ramstein Air Base, Germany, which is a key European
transit point for EUCOM and CENTCOM. Additionally, CENTCOM planning
officials said that the borders of Kuwait and Qatar could be shut down
in a pandemic, causing problems for transporting personnel and supplies
into Iraq and Afghanistan. EUCOM planning officials said they discussed
the need for information on decisions other nations may make with
officials from the Department of State to help mitigate the effect of
limited information from other countries. However, according to the
EUCOM officials, most countries are not at a point in their planning to
make decisions on border closures or transportation restrictions. The
EUCOM officials said they will assume there will be movement
restrictions for the purpose of developing their plan, but will not
develop specific plans for addressing the movement restrictions until
they receive more information. However, information on other nations'
decisions may not be available before an influenza pandemic. Developing
plans at the last minute to address other nations' decisions could
limit the COCOMs' ability to obtain or use certain assets, placing at
risk the COCOMs' ability to effectively protect personnel and continue
missions due to potential restrictions by other nations on ground, sea,
and air transportation during an influenza pandemic. For example, if a
nation decides to close its borders at the start of a pandemic, COCOMs
and installations may not be able to obtain needed supplies, such as
antivirals. Identifying specific options to mitigate the effects of
other nations' possible decisions in advance of an influenza pandemic
may help the COCOMs more fully develop their pandemic influenza plans,
provide more flexibility in the COCOMs' response to an influenza
pandemic, and better allow the COCOMs to continue ongoing missions.
COCOMs Have Not Yet Develped Options to Mitigate the Effects of
Reliance on Civilian Medical Care:
Officials at each of the geographic COCOMs expressed concern that the
COCOMs are reliant on civilian medical providers in the United States
and abroad to provide medical care for military personnel, dependents,
and beneficiaries. This is a factor that has hindered the COCOMs'
ability to plan for how personnel will access medical care during an
influenza pandemic. In fiscal year 2006, DOD provided health care to
more than 9 million active duty personnel, retirees, and their
dependents through the department's TRICARE program. TRICARE
beneficiaries can obtain health care through DOD's direct care system
of military hospitals and clinics or through DOD's purchased care
system of civilian providers. We reported that, in fiscal year 2005, an
estimated 75 percent of inpatient care and 65 percent of outpatient
care for TRICARE beneficiaries was delivered by civilian
providers.[Footnote 26] Medical and planning officials at each of the
five geographic COCOMs expressed concern that civilian medical
facilities would not be able to meet the medical needs of their
military personnel, dependents, and beneficiaries during an influenza
pandemic, either because there may not be sufficient capacity in the
civilian medical facilities or civilian medical facilities may choose
to treat their own citizens ahead of these personnel. While COCOMs
realistically cannot reduce their reliance on civilian medical
capabilities, at least one COCOM has taken actions to mitigate the
effect of the military's reliance on civilian medical care. EUCOM
planning officials said they have invited host nation officials to
planning conferences and met with at least two medical providers in
Germany to coordinate efforts. However, the COCOMs do not control the
civilian medical system and, therefore, cannot allocate resources or
guarantee treatment for personnel in the civilian medical system during
an influenza pandemic. Without options to mitigate the effects of DOD's
reliance on the civilian medical system, COCOMs' risk being unable to
protect personnel and carry out their missions during an influenza
pandemic.
COCOMs Have Not Yet Developed Options to Mitigate the Effects of
Reliance on Military Services for Medical Materiel:
Planning officials from eight of the nine COCOMs expressed concern that
their headquarters are tenants on military services' installations and,
therefore, are reliant on the military services to distribute medical
materiel and other supplies. This is a factor that has hindered the
COCOMs' ability to fully address how their headquarters will receive
medical materiel and other supplies during an influenza pandemic.
Medical and planning officials at two COCOMs expressed concern with the
variance among the military services' health-related policies and
priorities. For example, the officials said that each military service
has a different doctrine or policy on pandemic influenza-related health
issues, such as the distribution of vaccines, antivirals, and other
drugs. Although guidance from the ASD for Health Affairs is the same
for all of the military services, it could be applied differently among
the military services. For example, medical and planning officials from
four of the COCOMs noted that the military services would determine how
vaccines and antivirals would be used because these supplies would be
provided through the military services. This variance in policy
implementation could lead to different preparedness levels and limit
the operational control COCOM commanders have during a pandemic, which
could impair the COCOMs' ability to carry out their missions. At least
two of the COCOMs--JFCOM and STRATCOM--have taken steps to mitigate the
impact of this issue by participating in pandemic influenza planning
efforts with the installation where their headquarters are located,
according to planning officials. The reliance of COCOMs' headquarters
on the military services for plans, decisions, and supplies and the
COCOMs' lack of plans to mitigate the impact of that dependence could
impact the COCOMs' ability to maintain their own operations and
missions during an influenza pandemic.
Conclusions:
The COCOMs have taken numerous actions to plan and prepare for an
influenza pandemic, and their efforts continue. However, the COCOMs
have faced some management challenges that have and will continue to
impair their ability to plan and prepare for an influenza pandemic in a
unified and cohesive manner. Planning in an environment of tremendous
uncertainty is an extremely difficult and daunting task, but the
potential impact of an influenza pandemic on DOD's personnel and
operations makes sound planning all the more crucial. Additionally,
preparing for a pandemic can be helpful for preparing for and
responding to other disasters that may occur. While we recognize that
DOD's planning and preparedness efforts departmentwide continue to
evolve, failure to address these challenges could affect DOD's ability
to protect its personnel, maintain the military's readiness, conduct
ongoing operations abroad, carry out day-to-day functions of the
department, and provide civil support at home and humanitarian
assistance abroad during an influenza pandemic. Clarifying what is
expected of COCOMs and other organizations within DOD in planning and
preparing for an influenza pandemic, what constitutes fulfillment of
planning tasks, and the roles and responsibilities of key organizations
involved in DOD's pandemic influenza planning and preparedness efforts
could help lessen the potential for confusion among COCOM officials,
limit gaps or duplication in DOD's efforts, and increase the likelihood
that DOD will be prepared to efficiently and effectively respond to an
influenza pandemic. Additionally, linking expectations to resources
should help the COCOMs establish appropriate priorities and accomplish
the actions assigned to them from the national implementation plan, as
well as other planning and preparedness activities. Finally, while the
COCOMs cannot control certain factors that have hindered their
preparedness efforts, they can take various steps to mitigate their
effects on certain aspects of the COCOMs' plans, including developing
options to address these factors. Without taking steps to address these
challenges, DOD risks being insufficiently prepared to respond in a
unified manner to protect its personnel and conduct its missions during
an influenza pandemic.
Recommendations for Executive Action:
To reduce the potential for confusion, gaps, and duplications in the
COCOMs' pandemic influenza planning and preparedness efforts and
enhance the unity and cohesiveness of DOD's efforts, we recommend that
the Secretary of Defense instruct the ASD(HD&ASA) to issue guidance
that specifies the following:
* Which of the actions assigned to DOD in the Implementation Plan for
the National Strategy for Pandemic Influenza and other pandemic
influenza- related planning tasks apply to the individual COCOMs,
military services, and other organizations within DOD, as well as what
constitutes fulfillment of these actions.
* NORTHCOM's roles and responsibilities as global synchronizer relative
to the roles and responsibilities of the various organizations leading
and supporting the department's pandemic influenza planning.
To increase the likelihood that the COCOMs can effectively continue
their pandemic influenza planning and preparedness activities,
including accomplishing actions assigned to DOD in the national
implementation plan within established time frames, we recommend that
the Secretary of Defense instruct the ASD(HD&ASA) to work with the
Under Secretary of Defense (Comptroller) to identify the sources and
types of resources that COCOMs need to accomplish their pandemic
influenza planning and preparedness activities.
To increase the likelihood that COCOMs are more fully prepared to
protect personnel and perform ongoing missions during an influenza
pandemic, we recommend that the Secretary of Defense instruct the Joint
Staff to work with the COCOMs to develop options to mitigate the
effects of factors that are beyond the COCOMs' control, such as limited
detailed information from other federal agencies on the support
expected from DOD, lack of control over DOD's antiviral stockpile,
limited information on decisions that other nations may make during an
influenza pandemic, reliance on civilian medical providers for medical
care, and reliance on military services for medical materiel.
Agency Comments and Our Evaluation:
In written comments on a draft of this report, DOD concurred with all
of our recommendations and noted that the department is confident that
future plans will adequately address specific roles, resources, and
risk mitigation. DOD also provided us with technical comments, which we
incorporated in the report, as appropriate. DOD's comments are included
in appendix III. We also provided the Department of State an
opportunity to comment on a draft of the report, but the department had
no comments.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution of it until 30
days from the date of this letter. We will then send copies of this
report to the Chairman and Ranking Member of the Senate and House
Committees on Appropriations, Subcommittees on Defense; Senate and
House Committees on Armed Services; Senate Committee on Homeland
Security and Governmental Affairs; House Committee on Homeland
Security; and other interested congressional parties. We are also
sending copies of this report to the Secretary of Defense; Secretary of
State; Director, Office of Management and Budget; Chairman of the Joint
Chiefs of Staff; Commanders of CENTCOM, EUCOM, JFCOM, NORTHCOM, PACOM,
SOCOM, SOUTHCOM, STRATCOM, and TRANSCOM; and the Commander, U.S. Forces
Korea. We will also provide copies to others upon request. In addition,
this report will be available at no charge on GAO's Web site at
http://www.gao.gov.
If you or your staff have any questions concerning this report, please
contact me at (202) 512-5431 or by e-mail at dagostinod@gao.gov.
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. GAO staff who
made contributions to this report are listed in appendix IV.
Davi M. D'Agostino Director, Defense Capabilities and Management:
[End of section]
Appendix I: Actions Assigned to DOD as a Lead Agency in the National
Implementation Plan:
Action number: 4.1.1.3;
Action: DOD, in coordination with the Department of State and other
appropriate federal agencies, host nations, and regional alliance
military partners, shall, within 18 months: (1) conduct bilateral and
multilateral assessments of the avian and pandemic preparedness and
response plans of the militaries in partner nations or regional
alliances, such as NATO, focused on preparing for and mitigating the
effects of an outbreak on assigned mission accomplishment; (2) develop
solutions for identified national and regional military gaps; and (3)
develop and execute bilateral and multilateral military-to-military
influenza exercises to validate preparedness and response plans;
Measure of performance: all countries with endemic avian influenza
engaged by U.S. efforts; initial assessment and identification of
exercise timeline for the military of each key partner nation
completed;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 4.1.2.6;
Action: DOD, in coordination with the Department of State, host
nations, and regional alliance military partners, shall assist in
developing priority country military infection control and case
management capability through training programs, within 18 months;
Measure of performance: training programs carried out in all priority
countries with increased military infection control and case management
capability;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 4.1.8.4;
Action: The Department of Health and Human Services and DOD, in
coordination with the Department of State, shall enhance open source
information sharing efforts with international organizations and
agencies to facilitate the characterization of genetic sequences of
circulating strains of novel influenza viruses within 12 months;
Measure of performance: publication of all reported novel influenza
viruses which are sequenced;
Deadline to complete action[A]: Within 12 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Assistant Secretary of Defense (ASD) for Health
Affairs.
Action number: 4.2.2.5;
Action: DOD shall develop active and passive systems for inpatient and
outpatient disease surveillance at its institutions worldwide, with an
emphasis on index case and cluster identification, and develop
mechanisms for utilizing DOD epidemiological investigation experts in
international support efforts, to include validation of systems/tools
and improved outpatient/inpatient surveillance capabilities, within 18
months; Measure of performance: monitoring system and program to
utilize epidemiological investigation experts internationally are in
place;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 4.2.2.6;
Action: DOD shall monitor the health of military forces worldwide
(bases in the continental United States and outside of the continental
United States, deployed operational forces, exercises, units, etc.),
and in coordination with the Department of State, coordinate with
allied, coalition, and host nation public health communities to
investigate and respond to confirmed infectious disease outbreaks on
DOD installations, within 18 months; Measure of performance: medical
surveillance "watchboard" reports show results of routine monitoring,
number of validated outbreaks, and results of interventions;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 4.2.2.7;
Action: DOD, in coordination with the Department of State and with the
cooperation of the host nation, shall assist with influenza
surveillance of host nation populations in accordance with existing
treaties and international agreements, within 24 months; Measure of
performance: medical surveillance "watchboard" expanded to include host
nations;
Deadline to complete action[A]: Within 24 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 4.2.3.8;
Action: DOD, in coordination with the Department of Health and Human
Services, shall develop and refine its overseas virologic and
bacteriologic surveillance infrastructure through Global Emerging
Infections Surveillance and Response System and the DOD network of
overseas labs, including fully developing and implementing seasonal
influenza laboratory surveillance and an animal/ vector surveillance
plan linked with World Health Organization (WHO) pandemic phases,
within 18 months; Measure of performance: animal/ vector surveillance
plan and DOD overseas virologic surveillance network developed and
functional;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 4.2.3.9;
Action: DOD, in coordination with the Department of Health and Human
Services, shall prioritize international DOD laboratory research
efforts to develop, refine, and validate diagnostic methods to rapidly
identify pathogens, within 18 months; Measure of performance:
completion of prioritized research plan, resources identified, and
tasks assigned across DOD medical research facilities;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 4.2.3.10;
Action: DOD shall work with priority nations' military forces to assess
existing laboratory capacity, rapid response teams, and portable field
assay testing equipment, and fund essential commodities and training
necessary to achieve an effective national military diagnostic
capability, within 18 months; Measure of performance: assessments
completed, proposals accepted, and funding made available to priority
countries;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 4.2.4.2;
Action: DOD shall incorporate international public health reporting
requirements for exposed or ill military international travelers into
the geographic combatant commanders' pandemic influenza plans within 18
months; Measure of performance: reporting requirements incorporated
into geographic combatant commanders' pandemic influenza plans;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 4.3.2.2;
Action: DOD, in coordination with the Department of State, the
Department of Health and Human Services, the Department of
Transportation, and the Department of Homeland Security, shall limit
official DOD military travel between affected areas and the United
States; Measure of performance: DOD identifies military facilities in
the United States and outside of the continental United States that
will serve as the points of entry for all official travelers from
affected areas, within 6 months;
Deadline to complete action[A]: Within 6 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 5.1.1.5; Action: DOD, in coordination with the
Department of Homeland Security, the Department of Transportation, the
Department of Justice, and the Department of State, shall conduct an
assessment of military support related to transportation and borders
that may be requested during a pandemic and develop a comprehensive
contingency plan for Defense Support of Civil Authorities, within 18
months; Measure of performance: Defense Support of Civil Authorities
plan in place that addresses emergency transportation and border
support;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 5.3.4.8;
Action: DOD, in coordination with the Department of Homeland Security
and the Department of State, shall identify those domestic and foreign
airports and seaports that are considered strategic junctures for major
military deployments and evaluate whether additional risk-based
protective measures are needed, within 18 months; Measure of
performance: identification of critical air and seaports and evaluation
of additional risk-based procedures, completed;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 5.3.5.5; Action: DOD, when directed by the Secretary of
Defense and in accordance with law, shall monitor and report the status
of the military transportation system and those military assets that
may be requested to protect the borders, assess impacts (to include
operational impacts), and coordinate military services in support of
federal agencies and state, local, and tribal entities; Measure of
performance: when DOD activated, regular reports provided, impacts
assessed, and services coordinated as needed;
Deadline to complete action[A]: In response to an influenza pandemic;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 6.1.6.3;
Action: DOD, as part of its departmental implementation plan, shall
conduct a medical materiel requirements gap analysis and procure
necessary materiel to enhance Military Health System surge capacity,
within 18 months; Measure of performance: gap analysis completed and
necessary materiel procured;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 6.1.6.4;
Action: The Department of Health and Human Services, DOD, the
Department of Veterans Affairs, and the states shall maintain antiviral
and vaccine stockpiles in a manner consistent with the requirements of
the Food and Drug Administration's Shelf Life Extension Program and
explore the possibility of broadening the Shelf Life Extension Program
to include equivalently maintained state stockpiles, within 6 months;
Measure of performance: compliance with the Shelf Life Extension
Program requirements documented;
decision made on broadening the Shelf Life Extension Program to state
stockpiles;
Deadline to complete action[A]: Within 6 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 6.1.7.4;
Action: DOD shall establish stockpiles of vaccine against H5N1 and
other influenza subtypes determined to represent a pandemic threat
adequate to immunize approximately 1.35 million persons for military
use within 18 months of availability; Measure of performance:
sufficient vaccine against each influenza virus determined to represent
a pandemic threat in DOD stockpile to vaccinate 1.35 million persons;
Deadline to complete action[A]: Within 18 months of availability;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 6.1.9.3;
Action: DOD shall procure 2.4 million treatment courses of antiviral
medications and position them at locations worldwide within 18 months.
Measure of performance: aggregate 2.4 million treatment courses of
antiviral medications in DOD stockpiles;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 6.1.13.8;
Action: DOD shall supply military units and posts, installations,
bases, and stations with vaccine and antiviral medications according to
the schedule of priorities listed in the DOD pandemic influenza policy
and planning guidance, within 18 months;
Measure of performance: vaccine and antiviral medications procured;
DOD policy guidance developed on use and release of vaccine and
antiviral medications;
and worldwide distribution drill completed;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 6.2.2.9;
Action: DOD shall enhance influenza surveillance efforts within 6
months by: (1) ensuring that medical treatment facilities monitor the
Electronic Surveillance System for Early Notification of Community-
based Epidemics and provide additional information on suspected or
confirmed cases of pandemic influenza through their service
surveillance activities;
(2) ensuring that Public Health Emergency Officers report all suspected
or actual cases through appropriate DOD reporting channels, as well as
to the Centers for Disease Control and Prevention, state public health
authorities, and host nations;
and (3) posting results of aggregated surveillance on the DOD Pandemic
Influenza Watchboard;
all within 18 months;
Measure of performance: number of medical treatment facilities
performing Electronic Surveillance System for Early Notification of
Community- based Epidemics surveillance greater than 80 percent;
DOD reporting policy for public health emergencies, including pandemic
influenza, completed;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 6.2.3.4;
Action: Department of Health and Human Services-, DOD-, and Department
of Veterans Affairs-funded hospitals and health facilities shall have
access to improved rapid diagnostic tests for influenza A, including
influenza with pandemic potential, within 6 months of when tests become
available;
Deadline to complete action[A]: Within 6 months of when tests become
available;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 6.2.4.3;
Action: DOD and the Department of Veterans Affairs shall be prepared to
track and provide personnel and beneficiary health statistics and
develop enhanced methods to aggregate and analyze data documenting
influenza-like illness from their surveillance systems within 12
months;
Measure of performance: influenza tracking systems in place and
capturing beneficiary clinical encounters;
Deadline to complete action[A]: Within 12 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 6.3.2.4;
Action: As appropriate, DOD, in consultation with its combatant
commanders, shall implement movement restrictions and individual
protection and social distancing strategies (including unit shielding,
ship sortie, cancellation of public gatherings, drill, training, etc.)
within its posts, installations, bases, and stations. DOD personnel and
beneficiaries living off-base should comply with local community
containment guidance with respect to activities not directly related to
the installation. DOD shall be prepared to initiate within 18 months;
Measure of performance: the policies/procedures are in place for at-
risk DOD posts, installations, bases, stations, and for units to
conduct an annual training evaluation that includes restriction of
movement, shielding, personnel protection measures, health unit
isolation, and other measures necessary to prevent influenza
transmission;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 6.3.2.5;
Action: All Department of Health and Human Services-, DOD-, and
Department of Veterans Affairs-funded hospitals and health facilities
shall develop, test, and be prepared to implement infection control
campaigns for pandemic influenza, within 3 months;
Measure of performance: guidance materials on infection control
developed and disseminated on www.pandemicflu.gov and through other
channels;
Deadline to complete action[A]: Within 3 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 6.3.4.7;
Action: DOD shall enhance its public health response capabilities by:
(1) continuing to assign epidemiologists and preventive medicine
physicians within key operational settings;
(2) expanding ongoing DOD participation in the Centers for Disease
Control and Prevention's Epidemic Intelligence Service program;
and (3) within 18 months, fielding specific training programs for
Public Health Emergency Officers that address their roles and
responsibilities during a public health emergency;
Measure of performance: all military Public Health Emergency Officers
fully trained within 18 months;
increase military trainees in the Centers for Disease Control and
Prevention's Epidemic Intelligence Service program by 100 percent
within 5 years;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 6.3.7.2;
Action: DOD and Department of Veterans Affairs assets and capabilities
shall be postured to provide care for military personnel and eligible
civilians, contractors, dependants, other beneficiaries, and veterans
and shall be prepared to augment the medical response of state,
territorial, tribal, or local governments and other federal agencies
consistent with their Emergency Support Function #8--Public Health and
Medical Services support roles, within 3 months;
Measure of performance: DOD and Department of Veterans Affairs'
pandemic preparedness plans developed;
in a pandemic, adequate health response provided to military and
associated personnel;
Deadline to complete action[A]: Within 3 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 6.3.7.5;
Action: DOD shall develop and implement guidelines defining conditions
under which Reserve Component medical personnel providing health care
in nonmilitary health care facilities should be mobilized and deployed,
within 18 months;
Measure of performance: guidelines developed and implemented;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 6.3.8.2;
Action: DOD and the Department of Veterans Affairs, in coordination
with the Department of Health and Human Services, shall develop and
disseminate educational materials, coordinated with and complementary
to messages developed by the Department of Health and Human Services
but tailored for their respective departments, within 6 months;
Measure of performance: up- to-date risk communication material
published on DOD and;
Department of Veterans Affairs pandemic influenza Web sites, Department
of Health and Human Services Web site www.pandemicflu.gov, and in other
venues;
Deadline to complete action[A]: Within 6 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: ASD for Health Affairs.
Action number: 8.1.2.5;
Action: DOD, in consultation with the Department of Justice and the
National Guard Bureau, and in coordination with the states as such
training applies to support state law enforcement, shall assess the
training needs for National Guard forces in providing operational
assistance to state law enforcement under either federal (Title 10) or
state (Title 32 or State Active Duty) in a pandemic influenza outbreak
and provide appropriate training guidance to the states and territories
for units and personnel who will be tasked to provide this support,
within 18 months;
Measure of performance: guidance provided to all states;
Deadline to complete action[A]: Within 18 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 8.1.2.6;
Action: DOD, in consultation with the Department of Justice, shall
advise state governors of the procedures for requesting military
equipment and facilities, training, and maintenance support as
authorized by 10 U.S.C. §§ 372-74, within 6 months;
Measure of performance: all state governors advised;
Deadline to complete action[A]: Within 6 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Action number: 8.3.2.1;
Action: The Department of Justice, the Department of Homeland Security,
and DOD shall engage in contingency planning and related exercises to
ensure they are prepared to maintain essential operations and conduct
missions, as permitted by law, in support of quarantine enforcement
and/or assist state, local, and tribal entities in law enforcement
emergencies that may arise in the course of an outbreak, within 6
months;
Measure of performance: completed plans (validated by exercise[s]) for
supporting quarantine enforcement and/or law enforcement emergencies;
Deadline to complete action[A]: Within 6 months;
Lead Department of Defense (DOD) organization responsible for
implementing action: Joint Staff.
Source: Homeland Security Council and DOD.
[A] The deadline to complete these actions is based on the May 2006
issuance date of the national implementation plan. Therefore, actions
that were to be completed within 6 months were due in November 2006.
The Homeland Security Council issued a report on the federal
government's progress on the actions to be completed within 6 months of
the issuance of the national implementation plan. For more information,
see Homeland Security Council, National Strategy for Pandemic Influenza
Implementation Plan Summary of Progress (Washington, D.C.: December
2006). Six of the seven actions assigned to DOD as a lead agency were
reported to be complete; one action was not included in the report. We
did not assess whether DOD met the performance measures listed in the
plan for these actions since it was not part of this review.
[End of table]
[End of section]
Appendix II: Scope and Methodology:
[End of section]
To determine the actions the combatant commands (COCOM) have taken to
date to prepare for an influenza pandemic, we reviewed drafts of the
five geographic COCOMs' plans and one functional COCOM's plan that were
available at the time of our review. We did not evaluate these plans;
rather we used the plans to determine what actions the COCOMs have
taken and plan to take to prepare for an influenza pandemic.
Additionally we reviewed planning orders issued by the Joint Staff to
the COCOMs in November 2005 and April 2007, DOD's implementation plan
for pandemic influenza issued in August 2006, the Implementation Plan
for the National Strategy for Pandemic Influenza issued by the Homeland
Security Council in May 2006, DOD's budget requests for fiscal years
2007 and 2008 and appropriations for fiscal year 2007, and after-action
reports from exercises related to pandemic influenza. Furthermore, we
met with more than 200 officials involved in pandemic influenza
planning and preparedness efforts at the nine COCOMs, including
operational, medical, logistics, and continuity of operations planners;
budget analysts; intelligence analysts and planners; public affairs
professionals; humanitarian assistance liaisons; and representatives
from the office of the command surgeon, including officials involved in
force health protection activities. To better understand the extent of
the COCOMs' efforts to plan and prepare for an influenza pandemic, we
met with officials or, in one case, received written responses to our
questions from the following COCOMs and their subcomponents:
*Headquarters, U.S. Central Command, MacDill Air Force Base, Florida;
*Headquarters, U.S. European Command, Patch Barracks, Germany;
*Marine Forces Europe, Patch Barracks, Germany;
*Naval Forces Europe, Patch Barracks, Germany;
*Special Operations Command Europe, Patch Barracks, Germany;
*U.S. Air Forces Europe, Ramstein Air Base, Germany;
*U.S. Army Europe, Campbell Barracks, Germany;
*Installation Management Command Europe, Campbell Barracks, Germany;
*European Regional Medical Command, Campbell Barracks, Germany;
*U.S. Army Medical Materiel Command Europe, Pirmasens, Germany;
*Headquarters, U.S. Joint Forces Command, Norfolk, Virginia;
*Headquarters, U.S. Northern Command, Peterson Air Force Base, Colorado;
*Headquarters, U.S. Pacific Command, Camp H.M. Smith, Hawaii;
*Marine Forces Pacific, Camp H.M. Smith, Hawaii;
*Pacific Air Force, Hickam Air Force Base, Hawaii;
*Pacific Fleet, Naval Station Pearl Harbor, Hawaii;
*Special Operations Command Pacific, Camp H.M. Smith, Hawaii;
*U.S. Army Pacific, Fort Shafter, Hawaii;
*U.S. Forces Korea, Yongsan Army Garrison, South Korea;
*U.S. Naval Forces Korea, Yongsan Army Garrison, South Korea;
*7th Air Force, Osan Air Base, South Korea;
*18th Medical Command, Yongsan Army Garrison, South Korea;
*Installation Management Command Korea Regional Office, Yongsan Army
Garrison, South Korea;
*Installation Management Command Pacific, Fort Shafter, Hawaii;
*Tripler Army Medical Center, Hawaii;
*Headquarters, U.S. Southern Command, Miami, Florida;
*Headquarters, U.S. Special Operations Command, MacDill Air Force Base,
Florida;
*Headquarters, U.S. Strategic Command, Offutt Air Force Base, Nebraska;
and:
*Headquarters, U.S. Transportation Command, Scott Air Force Base,
Illinois;
We elected to meet with officials from the military service and special
operations subcomponents at the U.S. European Command and U.S. Pacific
Command because these two commands have had to address outbreaks of
H5N1 avian influenza in their areas of responsibility. We selected U.S.
Forces Korea because of the number of cases of H5N1 avian influenza in
South Korea and the large number of U.S. military personnel stationed
in U.S. Forces Korea's area of responsibility. Furthermore, to better
understand how the COCOMs' planning and preparedness efforts relate to
DOD's departmentwide planning efforts, we met in the Washington, D.C.,
area with officials from the Office of the Assistant Secretary of
Defense for Homeland Defense and Americas' Security Affairs, Office of
the Assistant Secretary of Defense for Health Affairs, and Joint Staff.
We also met with officials from the Department of State to better
understand their pandemic influenza planning and preparedness efforts,
as they relate to the COCOMs' efforts. We did not assess the efforts of
the individual installations to prepare for an influenza pandemic or
whether installations' implementation plans supported the COCOM or
military services' plans because many installations had not yet
completed their implementation plans and because our focus for this
report was on the COCOM-level planning and preparedness efforts.
To determine management challenges that COCOMs face as they continue
their planning efforts, we compared the COCOMs' actions to date to best
practices that we have identified in our prior work. Specifically, we
reviewed our previous work on risk management, influenza pandemics,
emergency preparedness, and overall management to determine whether
other issues or lessons learned addressed in these reports were
applicable to the COCOMs' pandemic influenza planning and preparedness
efforts. This work is referenced in the list of Related GAO Products at
the end of this report.
We conducted our review from September 2006 through April 2007 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix III: Comments from the Department of Defense:
Assistant Secretary Of Defense:
2600 Defense Pentagon:
Washington, Dc 20301-2600:
Homeland Defense:
MAY 2 2 2007:
Ms. Davi M. D'Agostino:
Director, Defense Capabilities and Management:
U. S. Government Accountability Office:
441 G. Street, N. W.
Washington, DC 20548:
Dear Ms. D'Agostino:
Thank you for the opportunity to respond to the GAO Draft Report,
"Influenza Pandemic: DoD Combatant Commands' Preparedness Efforts Could
Benefit from More Clearly Defined Roles, Resources, and Risk
Mitigation," dated April 25, 2007, (GAO Code 350786/GAO-07-696). The Department of Defense concurs with comments. Please find the attached matrix and supporting documentation. While it is policy not to release plans outside of the Department, DoD Components have been directed to establish reading rooms to facilitate GAO's review of applicable plans.
The report represents a snapshot in time and much has been accomplished
to facilitate the Department's planning efforts. We are confident that
future plans will adequately address specific roles, resources, and
risk mitigation.
Sincerely,
Signed by:
Peter F. Verga:
Acting Director:
Enclosure:
As stated:
GAO Draft Report:
"Influenza Pandemic: DoD Combatant Commands' Preparedness Efforts Could
Benefit from More Clearly Defined Roles, Resources, and Risk
Mitigation," April 25, 2007, (GAO Code 350786/GAO-07-696):
Department Of Defense Comments To The Recommendations:
Recommendation 1: Recommend that the Secretary of Defense instruct the
ASD for Homeland Defense and Americas' Security Affairs to issue
guidance that specifies the following:
Which of the actions assigned to DOD in the Implementation Plan for the
National Strategy for Pandemic Influenza and other pandemic influenza-
related planning tasks apply to the individual COCOMs, military
services, and other organizations within DOD, as well as what
constitutes fulfillment of these actions.
* NORTHCOM's roles and responsibilities as global synchronizer relative
to the roles and responsibilities of the various organizations leading
and supporting the department's pandemic influenza planning.
DOD Response: DoD concurs.
Recommendation 2: Recommend that the Secretary of Defense instruct the
Assistant Secretary of Defense for Homeland Defense and Americas'
Security Affairs to work with the Under Secretary of Defense
(Comptroller) to identify the sources and types of resources that
COCOMS need to accomplish their pandemic influenza planning and
preparedness activities.
DOD Response: DoD concurs.
Recommendation 3: Recommend that the Secretary of Defense instruct the
Joint Staff to work with the COCOMs to develop options to mitigate the
effects of factors that are beyond the COCOMs' control, such as limited
detailed information from other federal agencies on the support
expected from DOD, lack of control over to DOD's antiviral stockpile,
limited information on decisions that other nations may make during an
influenza pandemic, reliance on civilian medical providers for medical
care, and reliance on military services for medical material.
DOD Response: DoD concurs.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
[End of section]
GAO Contact:
Davi M. D'Agostino, 202-512-5431, dagostinod@gao.gov:
Staff Acknowledgments:
Mark A. Pross, Assistant Director; Susan Ditto; Nicole Gore; Simon
Hirschfeld; Aaron Johnson; and Hilary Murrish made key contributions to
this report.
[End of section]
Related GAO Products:
Homeland Security: Observations on DHS and FEMA Efforts to Prepare for
and Respond to Major and Catastrophic Disasters and Address Related
Recommendations and Legislation. GAO-07-835T. Washington, D.C.: May 15,
2007.
Financial Market Preparedness: Significant Progress Has Been Made, but
Pandemic Planning and Other Challenges Remain. GAO-07-399. Washington,
D.C.: March 29, 2007.
Public Health and Hospital Emergency Preparedness Programs: Evolution
of Performance Measurement Systems to Measure Progress. GAO-07-485R.
Washington, D.C.: March 23, 2007.
Homeland Security: Preparing for and Responding to Disasters. GAO-07-
395T. Washington, D.C.: March 9, 2007.
Homeland Security: Applying Risk Management Principles to Guide Federal
Investments. GAO-07-386T. Washington, D.C.: February 7, 2007.
Influenza Pandemic: DOD Has Taken Important Actions to Prepare, but
Accountability, Funding, and Communications Need to be Clearer and
Focused Departmentwide. GAO-06-1042. Washington, D.C.: September 21,
2006.
Hurricane Katrina: Better Plans and Exercises Need to Guide the
Military's Response to Catastrophic Natural Disasters. GAO-06-808T.
Washington, D.C.: May 25, 2006.
Hurricane Katrina: Better Plans and Exercises Needed to Guide the
Military's Response to Catastrophic Natural Disasters. GAO-06-643.
Washington, D.C.: May 15, 2006.
Continuity of Operations: Agencies Could Improve Planning for Telework
during Disruptions. GAO-06-740T. Washington, D.C.: May 11, 2006.
Hurricane Katrina: GAO's Preliminary Observations Regarding
Preparedness, Response, and Recovery. GAO-06-442T. Washington, D.C.:
March 8, 2006.
Emergency Preparedness and Response: Some Issues and Challenges
Associated with Major Emergency Incidents. GAO-06-467T. Washington,
D.C.: February 23, 2006.
Statement by Comptroller General David M. Walker on GAO's Preliminary
Observations Regarding Preparedness and Response to Hurricanes Katrina
and Rita. GAO-06-365R. Washington, D.C.: February 1, 2006.
Influenza Pandemic: Applying Lessons Learned from the 2004-05 Influenza
Vaccine Shortage. GAO-06-221T. Washington, D.C.: November 4, 2005.
Influenza Vaccine: Shortages in 2004-05 Season Underscore Need for
Better Preparation. GAO-05-984. Washington, D.C.: September 30, 2005.
Influenza Pandemic: Challenges in Preparedness and Response. GAO-05-
863T. Washington, D.C.: June 30, 2005.
Influenza Pandemic: Challenges Remain in Preparedness. GAO-05-760T.
Washington, D.C.: May 26, 2005.
Flu Vaccine: Recent Supply Shortages Underscore Ongoing Challenges. GAO-
05-177T. Washington, D.C.: November 18, 2004.
Emerging Infectious Diseases: Review of State and Federal Disease
Surveillance Efforts. GAO-04-877. Washington, D.C.: September 30, 2004.
Infectious Disease Preparedness: Federal Challenges in Responding to
Influenza Outbreaks. GAO-04-1100T. Washington, D.C.: September 28, 2004.
Emerging Infectious Diseases: Asian SARS Outbreak Challenged
International and National Responses. GAO-04-564. Washington, D.C.:
April 28, 2004.
Public Health Preparedness: Response Capacity Improving but Much
Remains to Be Accomplished. GAO-04-458T. Washington, D.C.: February 12,
2004.
HHS Bioterrorism Preparedness Programs: States Reported Progress but
Fell Short of Program Goals for 2002. GAO-04-360R. Washington, D.C.:
February 10, 2004.
Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but
Lack Certain Capacities for Bioterrorism Response. GAO-03-924.
Washington, D.C.: August 6, 2003.
Severe Acute Respiratory Syndrome: Established Infectious Disease
Control Measures Helped Contain Spread, But a Large-Scale Resurgence
May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003.
SARS Outbreak: Improvements to Public Health Capacity Are Needed for
Responding to Bioterrorism and Emerging Infectious Diseases. GAO-03-
769T. Washington, D.C.: May 7, 2003.
Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have
Improved Public Health Response Capacity, but Gaps Remain. GAO-03-654T.
Washington, D.C.: April 9, 2003.
Flu Vaccine: Steps Are Needed to Better Prepare for Possible Future
Shortages. GAO-01-786T. Washington, D.C.: May 30, 2001.
Flu Vaccine: Supply Problems Heighten Need to Ensure Access for High-
Risk People. GAO-01-624. Washington, D.C.: May 15, 2001.
Influenza Pandemic: Plan Needed for Federal and State Response. GAO-01-
4. Washington, D.C.: October 27, 2000.
(350786):
FOOTNOTES
[1] The 1957 "Asian flu" pandemic and 1968 "Hong Kong flu" pandemic
caused far fewer deaths--70,000 and 34,000, respectively, in the United
States--partly because of antibiotic treatment of secondary infections
and more aggressive support care.
[2] Homeland Security Council, National Strategy for Pandemic Influenza
(Washington, D.C.: November 2005).
[3] Homeland Security Council, Implementation Plan for the National
Strategy for Pandemic Influenza (Washington, D.C.: May 2006).
[4] DOD, Department of Defense Implementation Plan for Pandemic
Influenza (Arlington, Va.: August 2006).
[5] The national implementation plan generally identifies lead and
support roles for the actions federal agencies are responsible for
completing but it is not explicit in defining these roles or processes
for coordination and collaboration.
[6] The Office of the Under Secretary of Defense for Policy was
reorganized in December 2006. This reorganization included, among other
things, the Office of the Assistant Secretary of Defense for Homeland
Defense being renamed the Office of the Assistant Secretary of Defense
for Homeland Defense and Americas' Security Affairs. Throughout this
report we refer to the office by its current name.
[7] In February 2007, the Secretary of Defense announced that DOD will
establish a sixth COCOM with geographic responsibilities--the U.S.
Africa Command--which is expected to become operational by September
2008. Responsibility for African operations currently is divided among
EUCOM, CENTCOM, and PACOM.
[8] GAO, Influenza Pandemic: DOD Has Taken Important Actions to
Prepare, but Accountability, Funding, and Communications Need to be
Clearer and Focused Departmentwide, GAO-06-1042 (Washington, D.C.:
Sept. 21, 2006).
[9] GAO, Homeland Security: Preparing for and Responding to Disasters,
GAO-07-395T (Washington, D.C.: Mar. 9, 2007) and GAO, Emergency
Preparedness and Response: Some Issues and Challenges Associated with
Major Emergency Incidents, GAO-06-467T (Washington, D.C.: Feb. 23,
2006).
[10] GAO, Agencies' Annual Performance Plans Under the Results Act: An
Assessment Guide to Facilitate Congressional Decisionmaking, GAO/GGD/
AIMD-10.1.18 (Washington, D.C.: Feb. 1, 1998).
[11] GAO, Homeland Security: Applying Risk Management Principles to
Guide Federal Investments, GAO-07-386T (Washington, D.C.: Feb. 7, 2007)
and GAO, Hurricane Katrina: GAO's Preliminary Observations Regarding
Preparedness, Response, and Recovery, GAO-06-442T (Washington, D.C.:
Mar. 8, 2006).
[12] GAO-06-1042.
[13] GAO-07-395T.
[14] While Marine Forces Pacific will lead PACOM's international
support response in most of the command's area of responsibility, U.S.
Forces Korea will lead PACOM's international support response on the
Korean peninsula.
[15] The Public Health Emergency Officer is the primary medical
official designated to manage public health emergencies on
installations.
[16] The assumption of 40 percent absenteeism is based on the planning
assumptions for a severe pandemic in the national implementation plan.
[17] The Combatant Commander Initiative Fund contains funds that may be
requested by a COCOM commander and provided by the Chairman of the
Joint Chiefs of Staff for various activities, including humanitarian
and civil assistance, military training and education for military and
related civilian personnel of foreign countries, and personnel expenses
of defense personnel for bilateral or regional cooperation programs.
[GAO-07-395T] and GAO-06-467T.
[18] GAO-06-1042.
[19] GAO/GGD/AIMD-10.1.18.
[20] GAO-06-1042.
[21] Department of Defense, Emergency Supplemental Appropriations to
Address Hurricanes in the Gulf of Mexico, and Pandemic Influenza Act,
2006, Pub. L. No. 109-148 (2005). The act provided $120 million for
necessary expenses related to vaccine purchases, storage, expanded
avian influenza surveillance programs, equipment, essential information
management systems, and laboratory diagnostic equipment. Additionally,
$10 million was provided for surveillance, communication equipment, and
assistance to military partner nations for procuring protective
equipment.
[22] Congressional Research Service, Pandemic Influenza: Appropriations
for Public Health Preparedness and Response (Washington, D.C.: Mar. 23,
2007).
[GAO-07-386T] and GAO-06-442T.
[23] GAO, Hurricane Katrina: Better Plans and Exercises Need to Guide
the Military's Response to Catastrophic Natural Disasters, GAO-06-808T
(Washington, D.C.: May 25, 2006).
[24] GAO, Defense Health Care: Access to Care for Beneficiaries Who
Have Not Enrolled in TRICARE's Managed Care Option, GAO-07-48
(Washington, D.C.: Dec. 22, 2006).
[25] Because a pandemic strain has not emerged and an effective vaccine
needs to be a match to the actual pandemic virus, vaccine production
for the pandemic strain cannot begin until a pandemic virus emerges.
Vaccine production generally takes at least 6 to 8 months after a virus
strain has been identified and will, therefore, likely be in short
supply during a pandemic influenza outbreak. Antiviral drugs can also
contribute to the prevention and treatment of influenza. However, while
antiviral drugs may help prevent or mitigate influenza-related illness
or death until an effective vaccine becomes available, these drugs are
expected to be in short supply during a pandemic influenza outbreak.
[26] Global Health: Framework for Infectious Disease Surveillance. GAO/
NSIAD-00-205R. Washington, D.C.: July 20, 2000.
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