Pandemics: who's in charge?

The National Strategy for Pandemic Influenza, Part II, has arrived. It is up on the White House site (.pdf).

I've been paging through the hundreds of pages and find a lot to like, at least in tone and language. And some things that bother me. Like the not-so-minor matter of "Who's in charge?" Just days ago, based on earlier drafts of the plan it was reported the Department of Health and Human Services (DHHS) would be in overall charge. This seemed to resolve a dispute as to whether responsibility for the coordinated response would rest with DHHS or the Department of Homeland Security (DHS), the dysfunctional agency that so distinguished itself (in a negative sense) during Hurricane Katrina. (See here and here for previous posts on this.) But yesterday I heard Richard Knox, now NPR's senior health correspondent, say the plan as issued is not entirely clear on this issue, so I took a look. I think it is quite clear. Homeland Security is in charge:

It is important that the Federal Government have a defined mechanism for coordination of its response. The National Response Plan (NRP) is the primary mechanism for coordination of the Federal Government’s response to Incidents of National Significance, and will guide the Federal pandemic response. It defines Federal departmental responsibilities for sector-specific responses, and provides the structure and mechanisms for effective coordination among Federal, State, local, and tribal authorities, the private sector, and non-governmental organizations (NGOs). Pursuant to the NRP and Homeland Security Presidential Directive 5 (HSPD-5), the Secretary of Homeland Security is responsible for coordination of Federal operations and resources, establishment of reporting requirements, and conduct of ongoing communications with Federal, State, local, and tribal governments, the private sector, and NGOs. (Implementation Plan, page 3)

This says The Decider has already decided: under the National Response Plan, that in Incidents of National Significance (these are incidents that are capitalized, apparently), DHS is in charge. If the incident is a medical or public health emergency, Health and Human Services will provide the support function and be the government's spokesperson for public health issues, coordinating with DHS, who will in turn coordinate everyone else:

Pursuant to the NRP, as the primary agency and coordinator for Emergency Support Function #8 (Public Health and Medical Services), the Secretary of Health and Human Services will lead Federal health and medical response efforts and will be the principal Federal spokesperson for public health issues, coordinating closely with DHS on public messaging pertaining to the pandemic. Pursuant to HSPD-5, as the principal Federal official for domestic incident management, the Secretary of Homeland Security will provide coordination for Federal operations and resources, establish reporting requirements, and conduct ongoing communications with Federal, State, local, and tribal governments, the private sector, and NGOs. In the context of response to a pandemic, the Secretary of Homeland Security will coordinate overall non-medical support and response actions, and ensure necessary support to the Secretary of Health and Human Services’ coordination of public health and medical emergency response efforts. (Implementation Plan, page 3)

This "coordinating" stuff is really a lot of handwaving. The real action will unfold as these agencies interact, and when that happens this will be a true Federal Disaster Area:

A pandemic will present unique challenges to the coordination of the Federal response. First and foremost, the types of support that the Federal Government will provide to the Nation are of a different kind and character than those it traditionally provides to communities damaged by natural disasters. Second, although it may occur in discrete waves in any one locale, the national impact of a pandemic could last for many months. Finally, a pandemic is a sustained public health and medical emergency that will have sustained and profound consequences for the operation of critical infrastructure, the mobility of people and freight, and the global economy. Health and medical considerations will affect foreign policy, international trade and travel, domestic disease containment efforts, continuity of operations within the Federal Government, and many other aspects of the Federal response. (Implementation Plan, page 3)

"Unique challenges" is bureaucratese for "we have no idea how we are going to pull this off." Commonsense says that if you put the whole shebang in the hands of a screwed up agency (DHS) with a notorious penchant for throwing its weight around you are asking for trouble. Since its inception DHS has dominated any dispute between agencies. In this case this is also in line with the Bush administration's basic view that DHHS is a pile of bleeding hearts engaged in the illegitimate administration of entitlement programs.

The bottom line is that an agency with no expertise in medical and public health matters will be calling the shots regarding quarantine, transportation, resource allocation, use of federal resources and much else. If DHHS disagrees about something, that will be just too bad for DHHS. So DHS won the battle and the rest of us lost.

I'm sure they'll do a heck of a job.