    [Public Papers of the Presidents of the United States: George W. Bush (2007, Book II)]
    [October 18, 2007]
    [Pages 1343-1352]
    [From the U.S. Government Publishing Office www.gpo.gov]

    Directive on Public Health and Medical Preparedness
    October 18, 2007

     Homeland Security Presidential Directive/HSPD-21
    Subject: Public Health and Medical Preparedness

    Purpose

        (1) This directive establishes a National Strategy for Public Health
    and Medical Preparedness (Strategy), which builds upon principles set
    forth in Biodefense for the 21st Century (April 2004) and will transform
    our national approach to protecting the health of the American people
    against all disasters.

    Definitions

        (2) In this directive:
        (a) The term ``biosurveillance'' means the process of active data-
    gathering with appropriate analysis and interpretation of biosphere data
    that might relate to disease activity and threats to human or animal
    health--whether infectious, toxic, metabolic, or otherwise, and
    regardless of intentional or natural origin--in order to achieve early
    warning of health threats, early detection of health events, and overall
    situational awareness of disease activity;
        (b) The term ``catastrophic health event'' means any natural or
    manmade incident, including terrorism, that results in a number of ill
    or injured persons sufficient to overwhelm the capabilities of immediate
    local and regional emergency response and health care systems;
        (c) The term ``epidemiologic surveillance'' means the process of
    actively gathering and analyzing data related to human health and
    disease in a population in order to obtain early warning of human health
    events, rapid characterization of human disease events, and overall
    situational awareness of disease activity in the human population;
        (d) The term ``medical'' means the science and practice of
    maintenance of health and prevention, diagnosis, treatment, and
    alleviation of disease or injury and the provision of those services to
    individuals;
        (e) The term ``public health'' means the science and practice of
    protecting and improving the overall health of the community through
    disease prevention and early diagnosis, control of communicable
    diseases, health education, injury prevention, sanitation, and
    protection from environmental hazards;
        (f) The term ``public health and medical preparedness'' means the
    existence of plans, procedures, policies, training, and equipment
    necessary to maximize the ability to prevent, respond to, and recover
    from major events, including efforts that result in the capability to
    render an appropriate public health and medical response that will
    mitigate the effects of illness and injury, limit morbidity and
    mortality to the maximum extent possible, and sustain societal,
    economic, and political infrastructure; and
        (g) The terms ``State'' and ``local government,'' when used in a
    geographical sense, have the meanings ascribed to such terms
    respectively in section 2 of the Homeland Security Act of 2002 (6 U.S.C.
    101).

    Background

        (3) A catastrophic health event, such as a terrorist attack with a
    weapon of mass destruction (WMD), a naturally-occurring pandemic, or a
    calamitous meteorological or geological event, could cause tens or
    hundreds of thousands of casualties or more, weaken our economy, damage
    public morale and confidence, and threaten our national security. It is
    therefore critical that we establish a strategic vision that will enable
    a level of public health and medical preparedness sufficient to address
    a range of possible disasters.
        (4) The United States has made significant progress in public health
    and medical

    [[Page 1344]]

    preparedness since 2001, but we remain vulnerable to events that
    threaten the health of large populations. The attacks of September 11
    and Hurricane Katrina were the most significant recent disasters faced
    by the United States, yet casualty numbers were small in comparison to
    the 1995 Kobe earthquake; the 2003 Bam, Iran, earthquake; the 2004
    Sumatra tsunami; and what we would expect from a 1918-like influenza
    pandemic or large-scale WMD attack. Such events could immediately
    overwhelm our public health and medical systems.
        (5) This Strategy draws key principles from the National Strategy
    for Homeland Security (October 2007), the National Strategy to Combat
    Weapons of Mass Destruction (December 2002), and Biodefense for the 21st
    Century (April 2004) that can be generally applied to public health and
    medical preparedness. Those key principles are the following: (1)
    preparedness for all potential catastrophic health events; (2) vertical
    and horizontal coordination across levels of government, jurisdictions,
    and disciplines; (3) a regional approach to health preparedness; (4)
    engagement of the private sector, academia, and other nongovernmental
    entities in preparedness and response efforts; and (5) the important
    roles of individuals, families, and communities.
        (6) Present public health and medical preparedness plans incorporate
    the concept of ``surging'' existing medical and public health
    capabilities in response to an event that threatens a large number of
    lives. The assumption that conventional public health and medical
    systems can function effectively in catastrophic health events has,
    however, proved to be incorrect in real-world situations. Therefore, it
    is necessary to transform the national approach to health care in the
    context of a catastrophic health event in order to enable U.S. public
    health and medical systems to respond effectively to a broad range of
    incidents.
        (7) The most effective complex service delivery systems result from
    rigorous end-to-end system design. A critical and formal process by
    which the functions of public health and medical preparedness and
    response are designed to integrate all vertical (through all levels of
    government) and horizontal (across all sectors in communities)
    components can achieve a much greater capability than we currently have.
        (8) The United States has tremendous resources in both public and
    private sectors that could be used to prepare for and respond to a
    catastrophic health event. To exploit those resources fully, they must
    be organized in a rationally designed system that is incorporated into
    pre-event planning, deployed in a coordinated manner in response to an
    event, and guided by a constant and timely flow of relevant information
    during an event. This Strategy establishes principles and objectives to
    improve our ability to respond comprehensively to catastrophic health
    events. It also identifies critical antecedent components of this
    capability and directs the development of an implementation plan that
    will delineate further specific actions and guide the process to
    fruition.
        (9) This Strategy focuses on human public health and medical
    systems; it does not address other areas critical to overall public
    health and medical preparedness, such as animal health systems, food and
    agriculture defense, global partnerships in public health, health threat
    intelligence activities, domestic and international biosecurity, and
    basic and applied research in threat diseases and countermeasures.
    Efforts in those areas are addressed in other policy documents.
        (10) It is not possible to prevent all casualties in catastrophic
    events, but strategic improvements in our Federal, State, and local
    planning can prepare our Nation to deliver appropriate care to the
    largest possible number of people, lessen the impact on limited health
    care resources, and support the continuity of society and government.

    [[Page 1345]]

    Policy

        (11) It is the policy of the United States to plan and enable
    provision for the public health and medical needs of the American people
    in the case of a catastrophic health event through continual and timely
    flow of information during such an event and rapid public health and
    medical response that marshals all available national capabilities and
    capacities in a rapid and coordinated manner.

    Implementation Actions

        (12) Biodefense for the 21st Century provides a foundation for the
    transformation of our catastrophic health event response and
    preparedness efforts. Although the four pillars of that framework--
    Threat Awareness, Prevention and Protection, Surveillance and Detection,
    and Response and Recovery--were developed to guide our efforts to defend
    against a bioterrorist attack, they are applicable to a broad array of
    natural and manmade public health and medical challenges and are
    appropriate to serve as the core functions of the Strategy for Public
    Health and Medical Preparedness.
        (13) To accomplish our objectives, we must create a firm foundation
    for community medical preparedness. We will increase our efforts to
    inform citizens and empower communities, buttress our public health
    infrastructure, and explore options to relieve current pressures on our
    emergency departments and emergency medical systems so that they retain
    the flexibility to prepare for and respond to events.
        (14) Ultimately, the Nation must collectively support and facilitate
    the establishment of a discipline of disaster health. The specialty of
    emergency medicine evolved as a result of the recognition of the special
    considerations in emergency patient care, and similarly the recognition
    of the unique principles in disaster-related public health and medicine
    merit the establishment of their own formal discipline. Such a
    discipline will provide a foundation for doctrine, education, training,
    and research and will integrate preparedness into the public health and
    medical communities.

    Critical Components of Public Health and Medical Preparedness

        (15) Currently, the four most critical components of public health
    and medical preparedness are biosurveillance, countermeasure
    distribution, mass casualty care, and community resilience. Although
    those capabilities do not address all public health and medical
    preparedness requirements, they currently hold the greatest potential
    for mitigating illness and death and therefore will receive the highest
    priority in our public health and medical preparedness efforts. Those
    capabilities constitute the focus and major objectives of this Strategy.
        (16) Biosurveillance: The United States must develop a nationwide,
    robust, and integrated biosurveillance capability, with connections to
    international disease surveillance systems, in order to provide early
    warning and ongoing characterization of disease outbreaks in near real-
    time. Surveillance must use multiple modalities and an in-depth
    architecture. We must enhance clinician awareness and participation and
    strengthen laboratory diagnostic capabilities and capacity in order to
    recognize potential threats as early as possible. Integration of
    biosurveillance elements and other data (including human health, animal
    health, agricultural, meteorological, environmental, intelligence, and
    other data) will provide a comprehensive picture of the health of
    communities and the associated threat environment for incorporation into
    the national ``common operating picture.'' A central element of
    biosurveillance must be an epidemiologic surveillance system to monitor
    human disease activity across populations. That system must be
    sufficiently enabled to identify specific disease incidence and
    prevalence in heterogeneous populations and environments and must
    possess sufficient flexibility to tailor analyses to new syndromes and
    emerging diseases. State and local government health officials, public

    [[Page 1346]]

    and private sector health care institutions, and practicing clinicians
    must be involved in system design, and the overall system must be
    constructed with the principal objective of establishing or enhancing
    the capabilities of State and local government entities.
        (17) Countermeasure Stockpiling and Distribution: In the context of
    a catastrophic health event, rapid distribution of medical
    countermeasures (vaccines, drugs, and therapeutics) to a large
    population requires significant resources within individual communities.
    Few if any cities are presently able to meet the objective of dispensing
    countermeasures to their entire population within 48 hours after the
    decision to do so. Recognizing that State and local government
    authorities have the primary responsibility to protect their citizens,
    the Federal Government will create the appropriate framework and
    policies for sharing information on best practices and mechanisms to
    address the logistical challenges associated with this requirement. The
    Federal Government must work with nonfederal stakeholders to create
    effective templates for countermeasure distribution and dispensing that
    State and local government authorities can use to build their own
    capabilities.
        (18) Mass Casualty Care: The structure and operating principles of
    our day-to-day public health and medical systems cannot meet the needs
    created by a catastrophic health event. Collectively, our Nation must
    develop a disaster medical capability that can immediately re-orient and
    coordinate existing resources within all sectors to satisfy the needs of
    the population during a catastrophic health event. Mass casualty care
    response must be (1) rapid, (2) flexible, (3) scalable, (4) sustainable,
    (5) exhaustive (drawing upon all national resources), (6) comprehensive
    (addressing needs from acute to chronic care and including mental health
    and special needs populations), (7) integrated and coordinated, and (8)
    appropriate (delivering the correct treatment in the most ethical manner
    with available capabilities). We must enhance our capability to protect
    the physical and mental health of survivors; protect responders and
    health care providers; properly and respectfully dispose of the
    deceased; ensure continuity of society, economy, and government; and
    facilitate long-term recovery of affected citizens.
        (19) The establishment of a robust disaster health capability
    requires us to develop an operational concept for the medical response
    to catastrophic health events that is substantively distinct from and
    broader than that which guides day-to-day operations. In order to
    achieve that transformation, the Federal Government will facilitate and
    provide leadership for key stakeholders to establish the following four
    foundational elements: Doctrine, System Design, Capacity, and Education
    and Training. The establishment of those foundational elements must
    result from efforts within the relevant professional communities and
    will require many years, but the Federal Government can serve as an
    important catalyst for this process.
        (20) Community Resilience: The above components address the supply
    side of the preparedness function, ultimately providing enhanced
    services to our citizens. The demand side is of equal importance. Where
    local civic leaders, citizens, and families are educated regarding
    threats and are empowered to mitigate their own risk, where they are
    practiced in responding to events, where they have social networks to
    fall back upon, and where they have familiarity with local public health
    and medical systems, there will be community resilience that will
    significantly attenuate the requirement for additional assistance. The
    Federal Government must formulate a comprehensive plan for promoting
    community public health and medical preparedness to assist State and
    local authorities in building resilient communities in the face of
    potential catastrophic health events.

    [[Page 1347]]

    Biosurveillance

        (21) The Secretary of Health and Human Services shall establish an
    operational national epidemiologic surveillance system for human health,
    with international connectivity where appropriate, that is predicated on
    State, regional, and community-level capabilities and creates a
    networked system to allow for two-way information flow between and among
    Federal, State, and local government public health authorities and
    clinical health care providers. The system shall build upon existing
    Federal, State, and local surveillance systems where they exist and
    shall enable and provide incentive for public health agencies to
    implement local surveillance systems where they do not exist. To the
    extent feasible, the system shall be built using electronic health
    information systems. It shall incorporate flexibility and depth of data
    necessary to respond to previously unknown or emerging threats to public
    health and integrate its data into the national biosurveillance common
    operating picture as appropriate. The system shall protect patient
    privacy by restricting access to identifying information to the greatest
    extent possible and only to public health officials with a need to know.
    The Implementation Plan to be developed pursuant to section 43 of this
    directive shall specify milestones for this system.
        (22) Within 180 days after the date of this directive, the Secretary
    of Health and Human Services, in coordination with the Secretaries of
    Defense, Veterans Affairs, and Homeland Security, shall establish an
    Epidemiologic Surveillance Federal Advisory Committee, including
    representatives from State and local government public health
    authorities and appropriate private sector health care entities, in
    order to ensure that the Federal Government is meeting the goal of
    enabling State and local government public health surveillance
    capabilities.

    Countermeasure Stockpiling and Distribution

        (23) In accordance with the schedule set forth below, the Secretary
    of Health and Human Services, in coordination with the Secretary of
    Homeland Security, shall develop templates, using a variety of tools and
    including private sector resources when necessary, that provide minimum
    operational plans to enable communities to distribute and dispense
    countermeasures to their populations within 48 hours after a decision to
    do so. The Secretary of Health and Human Services shall ensure that this
    process utilizes current cooperative programs and engages Federal,
    State, local government, and private sector entities in template
    development, modeling, testing, and evaluation. The Secretary shall also
    assist State, local government, and regional entities in tailoring
    templates to fit differing geographic sizes, population densities, and
    demographics, and other unique or specific local needs. In carrying out
    such actions, the Secretary shall:
        (a) within 270 days after the date of this directive, (i) publish an
    initial template or templates meeting the requirements above, including
    basic testing of component distribution mechanisms and modeling of
    template systems to predict performance in large-scale implementation,
    (ii) establish standards and performance measures for State and local
    government countermeasure distribution systems, including demonstration
    of specific capabilities in tactical exercises in accordance with the
    National Exercise Program, and (iii) establish a process to gather
    performance data from State and local participants on a regular basis to
    assess readiness; and
        (b) within 180 days after the completion of the tasks set forth in
    (a), and with appropriate notice, commence collecting and using
    performance data and metrics as conditions for future public health
    preparedness grant funding.

    [[Page 1348]]

        (24) Within 270 days after the date of this directive, the Secretary
    of Health and Human Services, in coordination with the Secretaries of
    Defense, Veterans Affairs, and Homeland Security and the Attorney
    General, shall develop Federal Government capabilities and plans to
    complement or supplement State and local government distribution
    capacity, as appropriate and feasible, if such entities' resources are
    deemed insufficient to provide access to countermeasures in a timely
    manner in the event of a catastrophic health event.
        (25) The Secretary of Health and Human Services shall ensure that
    the priority-setting process for the acquisition of medical
    countermeasures and other critical medical materiel for the Strategic
    National Stockpile (SNS) is transparent and risk-informed with respect
    to the scope, quantities, and forms of the various products. Within 180
    days after the date of this directive, the Secretary, in coordination
    with the Secretaries of Defense, Homeland Security, and Veterans
    Affairs, shall establish a formal mechanism for the annual review of SNS
    composition and development of recommendations that utilizes input from
    accepted national risk assessments and threat assessments, national
    planning scenarios, national modeling resources, and subject matter
    experts. The results of each such annual review shall be provided to the
    Director of the Office of Management and Budget and the Assistant to the
    President for Homeland Security and Counterterrorism at the time of the
    Department of Health and Human Services' next budget submission.
        (26) Within 90 days after the date of this directive, the Secretary
    of Health and Human Services shall establish a process to share relevant
    information regarding the contents of the SNS with Federal, State, and
    local government health officers with appropriate clearances and a need
    to know.
        (27) Within 180 days after the date of this directive, the Secretary
    of Health and Human Services, in coordination with the Secretaries of
    State, Defense, Agriculture, Veterans Affairs, and Homeland Security,
    shall develop protocols for sharing countermeasures and medical goods
    between the SNS and other Federal stockpiles and shall explore
    appropriate reciprocal arrangements with foreign and international
    stockpiles of medical countermeasures to ensure the availability of
    necessary supplies for use in the United States.

    Mass Casualty Care

        (28) The Secretary of Health and Human Services, in coordination
    with the Secretaries of Defense, Veterans Affairs, and Homeland
    Security, shall directly engage relevant State and local government,
    academic, professional, and private sector entities and experts to
    provide feedback on the review of the National Disaster Medical System
    and national medical surge capacity required by the Pandemic and All-
    Hazards Preparedness Act (PAHPA) (Public Law 109-417). Within 270 days
    after the completion of such review, the Secretary shall identify,
    through a systems-based approach involving expertise from such entities
    and experts, high-priority gaps in mass casualty care capabilities, and
    shall submit to the Assistant to the President for Homeland Security and
    Counterterrorism a concept plan that identifies and coordinates all
    Federal, State, and local government and private sector public health
    and medical disaster response resources, and identifies options for
    addressing critical deficits, in order to achieve the system attributes
    described in this Strategy.
        (29) Within 180 days after the date of this directive, the Secretary
    of Health and Human Services, in coordination with the Secretaries of
    Defense, Veterans Affairs, and Homeland Security, shall:
        (a) build upon the analysis of Federal facility use to provide
    enhanced medical surge capacity in disasters required by section 302 of
    PAHPA to analyze the use of Federal medical facilities as a foundational
    element of public health and medical preparedness; and

    [[Page 1349]]

        (b) develop and implement plans and enter into agreements to
    integrate such facilities more effectively into national and regional
    education, training, and exercise preparedness activities.
        (30) The Secretary of Health and Human Services shall lead an
    interagency process, in coordination with the Secretaries of Defense,
    Veterans Affairs, and Homeland Security and the Attorney General, to
    identify any legal, regulatory, or other barriers to public health and
    medical preparedness and response from Federal, State, or local
    government or private sector sources that can be eliminated by
    appropriate regulatory or legislative action and shall, within 120 days
    after the date of this directive, submit a report on such barriers to
    the Assistant to the President for Homeland Security and
    Counterterrorism.
        (31) The impact of the ``worried well'' in past disasters is well
    documented, and it is evident that mitigating the mental health
    consequences of disasters can facilitate effective response. Recognizing
    that maintaining and restoring mental health in disasters has not
    received sufficient attention to date, within 180 days after the date of
    this directive, the Secretary of Health and Human Services, in
    coordination with the Secretaries of Defense, Veterans Affairs, and
    Homeland Security, shall establish a Federal Advisory Committee for
    Disaster Mental Health. The committee shall consist of appropriate
    subject matter experts and, within 180 days after its establishment,
    shall submit to the Secretary of Health and Human Services
    recommendations for protecting, preserving, and restoring individual and
    community mental health in catastrophic health event settings, including
    pre-event, intra-event, and post-event education, messaging, and
    interventions.

    Community Resilience

        (32) The Secretary of Health and Human Services, in coordination
    with the Secretaries of Defense, Veterans Affairs, and Homeland
    Security, shall ensure that core public health and medical curricula and
    training developed pursuant to PAHPA address the needs to improve
    individual, family, and institutional public health and medical
    preparedness, enhance private citizen opportunities for contributions to
    local, regional, and national preparedness and response, and build
    resilient communities.
        (33) Within 270 days after the date of this directive, the Secretary
    of Health and Human Services, in coordination with the Secretaries of
    Defense, Commerce, Labor, Education, Veterans Affairs, and Homeland
    Security and the Attorney General, shall submit to the President for
    approval, through the Assistant to the President for Homeland Security
    and Counterterrorism, a plan to promote comprehensive community medical
    preparedness.

    Risk Awareness

        (34) The Secretary of Homeland Security, in coordination with the
    Secretary of Health and Human Services, shall prepare an unclassified
    briefing for non-health professionals that clearly outlines the scope of
    the risks to public health posed by relevant threats and catastrophic
    health events (including attacks involving weapons of mass destruction),
    shall coordinate such briefing with the heads of other relevant
    executive departments and agencies, shall ensure that full use is made
    of Department of Defense expertise and resources, and shall ensure that
    all State governors and the mayors and senior county officials from the
    50 largest metropolitan statistical areas in the United States receive
    such briefing, unless specifically declined, within 150 days after the
    date of this directive.
        (35) Within 180 days after the date of this directive, the Secretary
    of Homeland Security, in coordination with the Attorney General, the
    Secretary of Health and

    [[Page 1350]]

    Human Services, and the Director of National Intelligence, shall
    establish a mechanism by which up-to-date and specific public health
    threat information shall be relayed, to the greatest extent possible and
    not inconsistent with the established guidance relating to the
    Information Sharing Environment, to relevant public health officials at
    the State and local government levels and shall initiate a process to
    ensure that qualified heads of State and local government entities have
    the opportunity to obtain appropriate security clearances so that they
    may receive classified threat information when applicable.

    Education and Training

        (36) Within 180 days after the date of this directive, the Secretary
    of Health and Human Services, in coordination with the Secretary of
    Homeland Security, shall develop and thereafter maintain processes for
    coordinating Federal grant programs for public health and medical
    preparedness using grant application guidance, investment
    justifications, reporting, program performance measures, and
    accountability for future funding in order to promote cross-sector,
    regional, and capability-based coordination, consistent with section 201
    of PAHPA and the National Preparedness Guidelines developed pursuant to
    Homeland Security Presidential Directive-8 of December 17, 2003
    (``National Preparedness'').
        (37) Within 1 year after the date of this directive, the Secretary
    of Health and Human Services, in coordination with the Secretaries of
    Defense, Transportation, Veterans Affairs, and Homeland Security, and
    consistent with section 304 of PAHPA, shall develop a mechanism to
    coordinate public health and medical disaster preparedness and response
    core curricula and training across executive departments and agencies,
    to ensure standardization and commonality of knowledge, procedures, and
    terms of reference within the Federal Government that also can be
    communicated to State and local government entities, as well as academia
    and the private sector.
        (38) Within 1 year after the date of this directive, the Secretaries
    of Health and Human Services and Defense, in coordination with the
    Secretaries of Veterans Affairs and Homeland Security, shall establish
    an academic Joint Program for Disaster Medicine and Public Health housed
    at a National Center for Disaster Medicine and Public Health at the
    Uniformed Services University of the Health Sciences. The Program shall
    lead Federal efforts to develop and propagate core curricula, training,
    and research related to medicine and public health in disasters. The
    Center will be an academic center of excellence in disaster medicine and
    public health, co-locating education and research in the related
    specialties of domestic medical preparedness and response, international
    health, international disaster and humanitarian medical assistance, and
    military medicine. Department of Health and Human Services and
    Department of Defense authorities will be used to carry out respective
    civilian and military missions within this joint program.

    Disaster Health System

        (39) Within 180 days after the date of this directive, the Secretary
    of Health and Human Services shall commission the Institute of Medicine
    to lead a forum engaging Federal, State, and local governments, the
    private sector, academia, and appropriate professional societies in a
    process to facilitate the development of national disaster public health
    and medicine doctrine and system design and to develop a strategy for
    long-term enhancement of disaster public health and medical capacity and
    the propagation of disaster public health and medicine education and
    training.
        (40) Within 120 days after the date of this directive, the Secretary
    of Health and Human Services shall submit to the President through the
    Assistant to the President

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    for Homeland Security and Counterterrorism, and shall commence the
    implementation of, a plan to use current grant funding programs, private
    payer incentives, market forces, Center for Medicare and Medicaid
    Services requirements, and other means to create financial incentives to
    enhance private sector health care facility preparedness in such a
    manner as to not increase health care costs.
        (41) Within 180 days after the date of this directive, the Secretary
    of Health and Human Services, in coordination with the Secretaries of
    Transportation and Homeland Security, shall establish within the
    Department of Health and Human Services an Office for Emergency Medical
    Care. Under the direction of the Secretary, such Office shall lead an
    enterprise to promote and fund research in emergency medicine and trauma
    health care; promote regional partnerships and more effective emergency
    medical systems in order to enhance appropriate triage, distribution,
    and care of routine community patients; promote local, regional, and
    State emergency medical systems' preparedness for and response to public
    health events. The Office shall address the full spectrum of issues that
    have an impact on care in hospital emergency departments, including the
    entire continuum of patient care from pre-hospital to disposition from
    emergency or trauma care. The Office shall coordinate with existing
    executive departments and agencies that perform functions relating to
    emergency medical systems in order to ensure unified strategy, policy,
    and implementation.

    National Health Security Strategy

        (42) The PAHPA requires that the Secretary of Health and Human
    Services submit in 2009, and quadrennially afterward, a National Health
    Security Strategy (NHSS) to the Congress. The principles and actions in
    this directive, and in the Implementation Plan required by section 43,
    shall be incorporated into the initial NHSS, as appropriate, and shall
    serve as a foundation for the preparedness goals contained therein.

    Task Force and Implementation Plan

        (43) In order to facilitate the implementation of the policy
    outlined in this Strategy, there is established the Public Health and
    Medical Preparedness Task Force (Task Force). Within 120 days after the
    date of this directive, the Task Force shall submit to the President for
    approval, through the Assistant to the President for Homeland Security
    and Counterterrorism, an Implementation Plan (Plan) for this Strategy,
    and annually thereafter shall submit to the Assistant to the President
    for Homeland Security and Counterterrorism a status report on the
    implementation of the Plan and any recommendations for changes to this
    Strategy.
        (a) The Task Force shall consist exclusively of the following
    members (or their designees who shall be full-time officers or employees
    of the members' respective agencies):
           (i)   The Secretary of Health and Human Services, who shall serve
                as Chair;
          (ii)   The Secretary of State;
          (ii)   The Secretary of Defense;
         (iii)   The Attorney General;
          (iv)   The Secretary of Agriculture;
           (v)   The Secretary of Commerce;
          (vi)   The Secretary of Labor;
         (vii)   The Secretary of Transportation;

     (viii)

                 The Secretary of Veterans Affairs
          (ix)   The Secretary of Homeland Security;
           (x)   The Director of the Office of Management and Budget;
          (xi)   The Director of National Intelligence; and
         (xii)   such other officers of the United States as the Chair of
                the Task Force may designate from time to time.
        (b) The Chair of the Task Force shall, as appropriate to deal with
    particular subject matters, establish subcommittees of the Task Force
    that shall consist exclusively of members of the Task Force (or their
    designees under subsection (a) of this section),

    [[Page 1352]]

    and such other full-time or permanent part-time officers or employees of
    the Federal Government as the Chair may designate.
        (c) The Plan shall:
           (i)   provide additional detailed roles and responsibilities of
                heads of executive departments and agencies relating to and
                consistent with the Strategy and actions set forth in this
                directive;
          (ii)   provide additional guidance on public health and medical
                directives in Biodefense for the 21st Century; and
         (iii)   direct the full examination of resource requirements.
        (d) The Plan and all Task Force reports shall be developed in
    coordination with the Biodefense Policy Coordination Committee of the
    Homeland Security Council and shall then be prepared for consideration
    by and submitted to the more senior committees of the Homeland Security
    Council, as deemed appropriate by the Assistant to the President for
    Homeland Security and Counterterrorism.

    General Provisions

        (44) This directive:
        (a) shall be implemented consistent with applicable law and the
    authorities of executive departments and agencies, or heads of such
    departments and agencies, vested by law, and subject to the availability
    of appropriations and within the current projected spending levels for
    Federal health entitlement programs;
        (b) shall not be construed to impair or otherwise affect the
    functions of the Director of the Office of Management and Budget
    relating to budget, administrative, and legislative proposals; and
        (c) is not intended, and does not, create any rights or benefits,
    substantive or procedural, enforceable at law or in equity by a party
    against the United States, its departments, agencies, instrumentalities,
    or entities, its officers, employees, or agents, or any other person.

    Note: An original was not available for verification of the content of
    this directive.