Influenza Pandemic: DOD Combatant Commands' Preparedness Efforts
Could Benefit from More Clearly Defined Roles, Resources, and
Risk Mitigation (20-JUN-07, GAO-07-696).
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.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-07-696
ACCNO: A71045
TITLE: Influenza Pandemic: DOD Combatant Commands' Preparedness
Efforts Could Benefit from More Clearly Defined Roles, Resources,
and Risk Mitigation
DATE: 06/20/2007
SUBJECT: Defense capabilities
Defense contingency planning
Emergency preparedness
Homeland security
Infectious diseases
Military forces
Pandemic
Public health
Strategic planning
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GAO-07-696
* [1]Results in Brief
* [2]Background
* [3]COCOMs Have Taken Numerous Actions to Prepare for an Influen
* [4]COCOMs Have Established Working Groups to Address Pandemic I
* [5]COCOMs Have Developed Pandemic Influenza Plans for Their Are
* [6]COCOMs Have Conducted Exercises for Pandemic Influenza Plans
* [7]COCOMs Have Started to Provide Information to Personnel abou
* [8]COCOMs Have Coordinated with Other Nations
* [9]COCOMs Face Three Management Challenges as They Continue to
* [10]Roles, Responsibilities, and Authorities of Key Organization
* [11]DOD Has Not Identified Resources to Complete Planning and Pr
* [12]COCOMs Have Not Yet Developed Options to Mitigate the Effect
* [13]COCOMs Have Not Yet Developed Options to Mitigate the
Effect
* [14]COCOMs Have Not Yet Developed Options to Mitigate the
Effect
* [15]COCOMs Have Not Yet Developed Options to Mitigate the
Effect
* [16]COCOMs Have Not Yet Develped Options to Mitigate the
Effects
* [17]COCOMs Have Not Yet Developed Options to Mitigate the
Effect
* [18]Conclusions
* [19]Recommendations for Executive Action
* [20]Agency Comments and Our Evaluation
* [21]Appendix I: Actions Assigned to DOD as a Lead Agency in the
* [22]Appendix II: Scope and Methodology
* [23]Appendix III: Comments from the Department of Defense
* [24]Appendix IV: GAO Contact and Staff Acknowledgments
* [25]GAO Contact
* [26]Staff Acknowledgments
* [27]Related GAO Products
* [28]PDF6-Ordering Information.pdf
* [29]Order by Mail or Phone
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
Contents
Letter 1
Results in Brief 6
Background 9
COCOMs Have Taken Numerous Actions to Prepare for an Influenza Pandemic 11
COCOMs Face Three Management Challenges as They Continue to Prepare for an
Influenza Pandemic 21
Conclusions 36
Recommendations for Executive Action 37
Agency Comments and Our Evaluation 38
Appendix I Actions Assigned to DOD as a Lead Agency in the National
Implementation Plan 40
Appendix II Scope and Methodology 47
Appendix III Comments from the Department of Defense 50
Appendix IV GAO Contact and Staff Acknowledgments 52
Related GAO Products 53
Tables
Table 1: Summary of COCOMs' Actions to Prepare for an Influenza Pandemic
12
Table 2: COCOM Perceptions of Responsibility for Actions Assigned to DOD
25
Figures
Figure 1: Geographic COCOMs' Areas of Responsibility 4
Figure 2: Comparison of WHO Pandemic Phases and Federal Government Stages
11
Figure 3: Timeline of COCOMs' Pandemic Influenza Planning Efforts 14
Figure 4: Official Provides Information about Pandemic Influenza at
PACOM's Outreach Event 19
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
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
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copyright holder may be necessary if you wish to reproduce this material
separately.
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.^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.
^1The 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.
To address the potential threat of an influenza pandemic, the Homeland
Security Council issued its National Strategy for Pandemic Influenza in
November 2005.^2 The Implementation Plan for the National Strategy for
Pandemic Influenza (national implementation plan),^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.^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.^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,^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.
^2Homeland Security Council, National Strategy for Pandemic Influenza
(Washington, D.C.: November 2005).
^3Homeland Security Council, Implementation Plan for the National Strategy
for Pandemic Influenza (Washington, D.C.: May 2006).
^4DOD, Department of Defense Implementation Plan for Pandemic Influenza
(Arlington, Va.: August 2006).
^5The 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.
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.^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.
^6The 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.
^7In 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.
Figure 1: Geographic COCOMs' Areas of Responsibility
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.
aThe state of Alaska is assigned to NORTHCOM's area of responsibility.
Forces based in Alaska, however, remain assigned to PACOM.
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.^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.
^8GAO, Influenza Pandemic: DOD Has Taken Important Actions to Prepare, but
Accountability, Funding, and Communications Need to be Clearer and Focused
Departmentwide, [30]GAO-06-1042 (Washington, D.C.: Sept. 21, 2006).
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:
o 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.^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.
o 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.^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.
o 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.^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.
^9GAO, Homeland Security: Preparing for and Responding to Disasters,
[31]GAO-07-395T (Washington, D.C.: Mar. 9, 2007) and GAO, Emergency
Preparedness and Response: Some Issues and Challenges Associated with
Major Emergency Incidents, [32]GAO-06-467T (Washington, D.C.: Feb. 23,
2006).
^10GAO, Agencies' Annual Performance Plans Under the Results Act: An
Assessment Guide to Facilitate Congressional Decisionmaking,
[33]GAO/GGD/AIMD-10.1.18 (Washington, D.C.: Feb. 1, 1998).
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.
^11GAO, Homeland Security: Applying Risk Management Principles to Guide
Federal Investments, [34]GAO-07-386T (Washington, D.C.: Feb. 7, 2007) and
GAO, Hurricane Katrina: GAO's Preliminary Observations Regarding
Preparedness, Response, and Recovery, [35]GAO-06-442T (Washington, D.C.:
Mar. 8, 2006).
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.^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.^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.
^12 [36]GAO-06-1042 .
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.
^13 [37]GAO-07-395T .
Figure 2: Comparison of WHO Pandemic Phases and Federal Government Stages
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 Established Developed Conducted Informed Coordinated with
command working groups plans exercises personnel other nations
CENTCOM X X X X
EUCOM X X X X X
JFCOM X
NORTHCOM X X X X X
PACOM X X X X X
SOCOM ^a
SOUTHCOM X X X X
STRATCOM X X X X
TRANSCOM X X
Source: GAO analysis of DOD data.
aSOCOM 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.
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.^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,^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.
^14While 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.
^15The Public Health Emergency Officer is the primary medical official
designated to manage public health emergencies on installations.
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
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.
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.^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
^16The assumption of 40 percent absenteeism is based on the planning
assumptions for a severe pandemic in the national implementation plan.
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,^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.
^17The 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.
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.^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,^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.
^18[38]GAO-07-395T and [39]GAO-06-467T .
^19 [40]GAO-06-1042 .
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
o 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;
o assessing and advocating for resources for the COCOMs, military
services, and defense agencies; and
o 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. S 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 Action assigned to DOD CENTCOM EUCOM NORTHCOM PACOM SOUTHCOM
4.1.1.3 Conduct X X X X X
military-to-military
assistance planning
4.1.2.6 Priority country X X X X X
military-to-military
infection control training
4.1.8.4 Open source information X
sharing
4.2.2.5 Inpatient and outpatient X X X
disease surveillance
4.2.2.6 Monitoring health of X X X
military forces worldwide
4.2.2.7 Assist with influenza X X X
surveillance in host
nations
4.2.3.8 Develop/enhance DOD network
of overseas
infrastructure^a
4.2.3.9 Refinement of DOD X X
laboratory methods
4.2.3.10 Assess foreign country X X X X X
military laboratory
capacity
4.2.4.2 COCOM public health reports X X X X X
for area personnel
4.3.2.2 Identify DOD facilities to X X X X
serve as points of entry
from outbreak countries
5.1.1.5 Assessment of military X X X
support for transportation
and borders
5.3.4.8 Strategic military X X X X
deployment use of airports
and seaports
5.3.5.5 Monitor and report on X
military assets requested
for border protection
6.1.6.3 Conduct medical materiel X X X
requirements gap analysis
6.1.6.4 Maintain antiviral and
vaccine stockpiles^a
6.1.7.4 Establish stockpiles of
vaccine against H5N1^a
6.1.9.3 Procure 2.4 million
antiviral medications^a
6.1.13.8 Supply military units/bases X
with influenza medication
6.2.2.9 Enhance public health X X X
response capabilities
6.2.3.4 Access to improved rapid X X
diagnostic tests
6.2.4.3 Provide health statistics X
on influenza-like illnesses
6.3.2.4 DOD guidance to personnel X X X X X
on protective measures
6.3.2.5 Implement infection control X X
campaigns
6.3.4.7 Enhance influenza X X
surveillance reporting
techniques
6.3.7.2 Be prepared to augment X X
state/local government
medical response
6.3.7.5 Reserve medical personnel
mobilization^a
6.3.8.2 Update risk communication X X
material
8.1.2.5 National Guard training for
state law enforcement^a
8.1.2.6 Requests for assistance X
from states/governors
8.3.2.1 Plans for quarantine X X X
enforcement
Total 15 18 12 13 13
Source: GAO analysis of DOD data.
aNone 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.
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.^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.^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.
^20 [41]GAO/GGD/AIMD-10.1.18 .
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.^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.^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.
^21 [42]GAO-06-1042 .
^22Department 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.
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.
^23Congressional Research Service, Pandemic Influenza: Appropriations for
Public Health Preparedness and Response (Washington, D.C.: Mar. 23, 2007).
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.^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.
^24[43]GAO-07-386T and [44]GAO-06-442T .
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.^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.
^25GAO, Hurricane Katrina: Better Plans and Exercises Need to Guide the
Military's Response to Catastrophic Natural Disasters, [45]GAO-06-808T
(Washington, D.C.: May 25, 2006).
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.^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.
^26GAO, Defense Health Care: Access to Care for Beneficiaries Who Have Not
Enrolled in TRICARE's Managed Care Option, [46]GAO-07-48 (Washington,
D.C.: Dec. 22, 2006).
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.^27 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.
^27Because 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.
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:
o 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.
o 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 [47]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 [48][email protected] .
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
Appendix I: Actions Assigned to DOD as a Lead Agency in the National
Implementation Plan
Lead Department
of Defense
(DOD)
organization
Deadline to responsible for
Action complete implementing
number Action action^a action
4.1.1.3 DOD, in coordination with the Within 18 Joint Staff
Department of State and other months
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.
4.1.2.6 DOD, in coordination with the Within 18 Joint Staff
Department of State, host months
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.
4.1.8.4 The Department of Health and Within 12 Assistant
Human Services and DOD, in months Secretary of
coordination with the Department Defense (ASD)
of State, shall enhance open for Health
source information sharing Affairs
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.
4.2.2.5 DOD shall develop active and Within 18 ASD for Health
passive systems for inpatient and months Affairs
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.
4.2.2.6 DOD shall monitor the health of Within 18 ASD for Health
military forces worldwide (bases months Affairs
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.
4.2.2.7 DOD, in coordination with the Within 24 ASD for Health
Department of State and with the months Affairs
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.
4.2.3.8 DOD, in coordination with the Within 18 ASD for Health
Department of Health and Human months Affairs
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.
4.2.3.9 DOD, in coordination with the Within 18 Joint Staff
Department of Health and Human months
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.
4.2.3.10 DOD shall work with priority Within 18 Joint Staff
nations' military forces to months
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.
4.2.4.2 DOD shall incorporate Within 18 ASD for Health
international public health months Affairs
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.
4.3.2.2 DOD, in coordination with the Within 6 months Joint Staff
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.
5.1.1.5 DOD, in coordination with the Within 18 Joint Staff
Department of Homeland Security, months
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.
5.3.4.8 DOD, in coordination with the Within 18 Joint Staff
Department of Homeland Security months
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.
5.3.5.5 DOD, when directed by the In response to Joint Staff
Secretary of Defense and in an influenza
accordance with law, shall pandemic
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.
6.1.6.3 DOD, as part of its departmental Within 18 ASD for Health
implementation plan, shall months Affairs
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.
6.1.6.4 The Department of Health and Within 6 months ASD for Health
Human Services, DOD, the Affairs
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.
6.1.7.4 DOD shall establish stockpiles of Within 18 ASD for Health
vaccine against H5N1 and other months of Affairs
influenza subtypes determined to availability
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.
6.1.9.3 DOD shall procure 2.4 million Within 18 ASD for Health
treatment courses of antiviral months Affairs
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.
6.1.13.8 DOD shall supply military units Within 18 Joint Staff
and posts, installations, bases, months
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.
6.2.2.9 DOD shall enhance influenza Within 18 ASD for Health
surveillance efforts within 6 months Affairs
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.
6.2.3.4 Department of Health and Human Within 6 months ASD for Health
Services-, DOD-, and Department of when tests Affairs
of Veterans Affairs-funded become
hospitals and health facilities available
shall have access to improved
rapid diagnostic tests for
influenza A, including influenza
with pandemic potential, within 6
months of when tests become
available.
6.2.4.3 DOD and the Department of Within 12 ASD for Health
Veterans Affairs shall be months Affairs
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.
6.3.2.4 As appropriate, DOD, in Within 18 Joint Staff
consultation with its combatant months
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.
6.3.2.5 All Department of Health and Within 3 months ASD for Health
Human Services-, DOD-, and Affairs
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.
6.3.4.7 DOD shall enhance its public Within 18 Joint Staff
health response capabilities by: months
(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.
6.3.7.2 DOD and Department of Veterans Within 3 months Joint Staff
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.
6.3.7.5 DOD shall develop and implement Within 18 ASD for Health
guidelines defining conditions months Affairs
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.
6.3.8.2 DOD and the Department of Within 6 months ASD for Health
Veterans Affairs, in coordination Affairs
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.
8.1.2.5 DOD, in consultation with the Within 18 Joint Staff
Department of Justice and the months
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.
8.1.2.6 DOD, in consultation with the Within 6 months Joint Staff
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. SS 372-74, within 6
months.
Measure of performance: all state
governors advised.
8.3.2.1 The Department of Justice, the Within 6 months Joint Staff
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.
Source: Homeland Security Council and DOD.
aThe 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.
Appendix II: Scope and Methodology
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:
o Headquarters, U.S. Central Command, MacDill Air Force Base,
Florida;
o Headquarters, U.S. European Command, Patch Barracks, Germany;
o Marine Forces Europe, Patch Barracks, Germany;
o Naval Forces Europe, Patch Barracks, Germany;
o Special Operations Command Europe, Patch Barracks,
Germany;
o U.S. Air Forces Europe, Ramstein Air Base, Germany;
o U.S. Army Europe, Campbell Barracks, Germany;
o Installation Management Command Europe, Campbell
Barracks, Germany;
o European Regional Medical Command, Campbell
Barracks, Germany;
o U.S. Army Medical Materiel Command Europe,
Pirmasens, Germany;
o Headquarters, U.S. Joint Forces Command, Norfolk, Virginia;
o Headquarters, U.S. Northern Command, Peterson Air Force Base,
Colorado;
o Headquarters, U.S. Pacific Command, Camp H.M. Smith, Hawaii;
o Marine Forces Pacific, Camp H.M. Smith, Hawaii;
o Pacific Air Force, Hickam Air Force Base, Hawaii;
o Pacific Fleet, Naval Station Pearl Harbor, Hawaii;
o Special Operations Command Pacific, Camp H.M.
Smith, Hawaii;
o U.S. Army Pacific, Fort Shafter, Hawaii;
o U.S. Forces Korea, Yongsan Army Garrison, South
Korea;
o U.S. Naval Forces Korea, Yongsan Army
Garrison, South Korea;
o 7th Air Force, Osan Air Base, South
Korea;
o 18th Medical Command, Yongsan Army
Garrison, South Korea;
o Installation Management Command Korea
Regional Office, Yongsan Army Garrison,
South Korea;
o Installation Management Command Pacific, Fort
Shafter, Hawaii;
o Tripler Army Medical Center, Hawaii;
o Headquarters, U.S. Southern Command, Miami, Florida;
o Headquarters, U.S. Special Operations Command, MacDill Air Force
Base, Florida;
o Headquarters, U.S. Strategic Command, Offutt Air Force Base,
Nebraska; and
o 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.
Appendix III: Comments from the Department of Defense
Appendix IV: GAO Contact and Staff Acknowledgments
GAO Contact
Davi M. D'Agostino, 202-512-5431, [49][email protected]
Staff Acknowledgments
Mark A. Pross, Assistant Director; Susan Ditto; Nicole Gore; Simon
Hirschfeld; Aaron Johnson; and Hilary Murrish made key contributions to
this report.
Related GAO Products
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Respond to Major and Catastrophic Disasters and Address Related
Recommendations and Legislation. [50]GAO-07-835T . Washington, D.C.: May
15, 2007.
Financial Market Preparedness: Significant Progress Has Been Made, but
Pandemic Planning and Other Challenges Remain. [51]GAO-07-399 .
Washington, D.C.: March 29, 2007.
Public Health and Hospital Emergency Preparedness Programs: Evolution of
Performance Measurement Systems to Measure Progress. [52]GAO-07-485R .
Washington, D.C.: March 23, 2007.
Homeland Security: Preparing for and Responding to Disasters.
[53]GAO-07-395T . Washington, D.C.: March 9, 2007.
Homeland Security: Applying Risk Management Principles to Guide Federal
Investments. [54]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. [55]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. [56]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. [57]GAO-06-643 .
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during Disruptions. [58]GAO-06-740T . Washington, D.C.: May 11, 2006.
Hurricane Katrina: GAO's Preliminary Observations Regarding Preparedness,
Response, and Recovery. [59]GAO-06-442T . Washington, D.C.: March 8, 2006.
Emergency Preparedness and Response: Some Issues and Challenges Associated
with Major Emergency Incidents. [60]GAO-06-467T . Washington, D.C.:
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Statement by Comptroller General David M. Walker on GAO's Preliminary
Observations Regarding Preparedness and Response to Hurricanes Katrina and
Rita. [61]GAO-06-365R . Washington, D.C.: February 1, 2006.
Influenza Pandemic: Applying Lessons Learned from the 2004-05 Influenza
Vaccine Shortage. [62]GAO-06-221T . Washington, D.C.: November 4, 2005.
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and National Responses. [69]GAO-04-564 . Washington, D.C.: April 28, 2004.
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[74]GAO-03-769T . Washington, D.C.: May 7, 2003.
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[79]GAO/NSIAD-00-205R . Washington, D.C.: July 20, 2000.
(350786)
[80]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
[email protected].
Highlights of [81]GAO-07-696 , a report to the Committee on Oversight and
Government Reform, House of Representatives
June 2007
INFLUENZA PANDEMIC
DOD Combatant Commands' Preparedness Efforts Could Benefit from More
Clearly Defined Roles, Resources, and Risk Mitigation
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.
[82]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.
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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Public Affairs
Paul Anderson, Managing Director, [88][email protected] (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, D.C. 20548
References
Visible links
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