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Although it may not have been readily apparent in early 2020, the federal government did have a comprehensive national strategy and plan for a pandemic threat in the November 2005 “National Strategy for Pandemic Influenza” (Strategy) and its May 2006 “National Strategy for Pandemic Influenza – Implementation Plan” (Plan). The documents provide guidance and a detailed framework for planning at all levels of government in conjunction with the private sector and foreign partners. The Plan was released in 2006 to implement the higher-level pandemic strategy from 2005. The two essential documents included influenza in their titles, but they were relevant for any pandemic or vast public health threat – including a novel coronavirus. According to the Plan:
The goals of the Federal Government response to a pandemic are to: (1) stop, slow, or otherwise limit the spread of a pandemic to the United States; (2) limit the domestic spread of a pandemic, and mitigate disease, suffering and death; and (3) sustain infrastructure and mitigate impact to the economy and the functioning of society.
The Strategy contained three pillars:
Preparedness and communication,
Surveillance and detection, and
Response and containment.
The Plan identified over 300 detailed domestic and international actions and expectations to prepare the nation for a pandemic. Many of the actions provided a time period for execution or completion without an established process to ensure compliance and achievement. If fully executed with continued focus and oversight on the actions and expectations, the response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel virus that caused the COVID-19 pandemic, may have been more successful without many of the staggering short and long-term consequences experienced in the United States.
Latino COVID testing site, Detroit, Michigan (Source: City of Detroit, October 2020).
The nine chapters of the Plan from 16 years ago are just as relevant today for SARS-CoV-2 or for the next international public health threat be it naturally occurring or man-made. The retrieval and review of both documents would be beneficial to protect the nation when faced with future biological threats or incidents to include the current concerns over the monkeypox virus.
The updating and consistent execution of the actions and expectations would better prepare the nation for the next inevitable serious pathogenic threat with one major addition – a person with true authority and power to ensure that the federal departments and agencies adopt and maintain their concentration and capabilities. The person would have to be able to convincingly organize and oversee federal efforts and deliver meaningful consequences for intergovernmental resistance.
The Plan clearly identified and directed high-level guidance in 2006 to establish priorities, planning, and preparedness across the government. There were expectations that national plans would utilize a logical whole-of-government approach in planning and preparedness.
Develop Federal implementation plans to support the National Strategy for Pandemic Influenza, to include all components of the U.S. Government and to address the full range of consequences of a pandemic. (p. 85)
These actions and expectations included the critical areas of law enforcement and public safety that are vital for an intergovernmental approach. A review of the actions and expectations demonstrates the broad intention of coordination across the government to include state, local, and tribal partners. Some of these Plan actions are provided below in their entirety to demonstrate their comprehensiveness, relevance, and importance.
Develop Federal implementation plans on law enforcement and public safety, to include all components of the Federal Government and to address the full range of consequences of a pandemic, including human and animal health, security, transportation, economic, trade, and infrastructure considerations. Ensure appropriate coordination with State, local, and tribal governments. (8.1.1)
States should ensure that pandemic response plans adequately address law enforcement and public safety preparedness across the range of response actions that may be implemented, and that these plans are integrated with authorities that may be exercised by Federal agencies and other State, local, and tribal governments. (126.96.36.199)
DHS, in coordination with DOJ, HHS, DOL, and DOD, shall develop a pandemic influenza tabletop exercise for State, local, and tribal law enforcement/public safety officials that they can conduct in concert with public health and medical partners, and ensure it is distributed nationwide within 4 months. (188.8.131.52)
State, local, and tribal governments should review their legal authorities that may be needed to respond to an influenza pandemic, identify needed changes in the law, and pursue legislative action as appropriate. (184.108.40.206)
States should ensure pandemic response plans address EMS, fire, public works, emergency management, and other emergency response and public safety preparedness. (220.127.116.11)
The average observer may not agree that the above actions and expectations were consistently implemented and maintained between 2006 and the arrival of COVID-19. With the continuing and cascading negative societal, financial, political, and public health consequences of the pandemic, the lasting impact of the 300 actions and expectations appeared minimal.
Surveillance and Early Detection
According to the Plan, surveillance and early detection warning of a pandemic was critical to be able to rapidly engage resources to contain the spread of the virus. An effective detection system was required to activate response plans and save lives before the appearance of a pandemic pathogen. To accomplish this task, five pivotal federal departments were identified to work together.
DHS will work closely with DOT, HHS, USDA, and DOS to develop and be prepared to implement screening protocols to enhance pre-departure, en route, and arrival screening at the U.S. border (land, air, and sea) for potentially infected travelers, animals, and other cargo. (p. 89)
The federal government was to provide guidance to the private sector and critical infrastructure partners to assist in their planning and preparedness to maintain essential services with decreased staffing during a pandemic. A public and private partnership would provide a broader and stronger capability for surveillance and early detection. The plan identified actions that became considerably more apparent with the arrival and response to COVID-19.
Develop mechanisms to rapidly share information on travelers who may be carrying or may have been exposed to a pandemic strain of influenza, for the purposes of contact tracing and outbreak investigation. (4.2.4)
DHS, in coordination with HHS, DOT, DOS, and DOD, shall work closely with domestic and international air carriers and cruise lines to develop and implement protocols (in accordance with U.S. privacy law) to retrieve and rapidly share information on travelers who may be carrying or may have been exposed to a pandemic strain of influenza, within 6 months. (18.104.22.168)
Successful screening detection operations would require the timely implementation of the next step in the process of the public health and law enforcement response for possible medical care and quarantine activities.
Quarantine and Isolation
The Plan encouraged all levels of government, domestically and internationally, to take appropriate and lawful action to contain a disease outbreak within the borders of their community, state, and country. To further this goal, the Plan directed coordination in the area of quarantine planning and enforcement by several large and diverse federal departments.
HHS, in coordination with DOJ, DOS, and DHS, shall determine when and how it will assist States in enforcing their quarantines and how it will enforce a Federal quarantine, within 9 months. (22.214.171.124)
This action, to be completed in early 2007, may have been one of the more important actions that should have been fully executed and maintained to better understand quarantines and isolation authorities, capabilities, and techniques before the pandemic or other significant public health threat. This clarification and leadership could have reduced the massive confusion regarding the rather undefined or misunderstood definitions of a shutdown, lockdown, shelter-in-place, and stay-at-home for guidance, requests, or orders. The term quarantine was often inaccurately intermixed with the other ambiguous terms that restricted movement on some level for a public health concern. It caused confusion and angst that will likely reappear during the next public health or homeland security emergency. However, it may also have tainted the true concept of quarantine for a public health threat, which could negatively impact its implementation in the future.
In the Plan, the Centers for Disease Control and Prevention (CDC) established recommendations for managing possibly infected air passengers:
with pandemic potential include isolation of ill persons, quarantine of all non-ill travelers … and targeted treatment and prophylaxis with … medications. The federal government … [was tasked to] … develop criteria and protocols for isolation and quarantine of travelers early in a pandemic, prior to significant spread of the virus in the United States. (p. 7)
As discussed in a previous 2021 article regarding limited federal resources, customs officers in the United States are responsible for the enforcement of federal quarantine orders to support the lead agency CDC at the border or within the United States between state borders. U.S. Customs and Border Protection (CBP) and U.S. Coast Guard (USCG) officers are authorized to help enforce federal quarantine orders. In addition to CBP and USCG, thousands of designated customs officers from the U.S. Immigration and Customs Enforcement (ICE) would be required to support the enforcement at the border or other interior locations. Customs officers, supporting Title 42, are the personnel within CBP, USCG, and ICE who have legally designated customs authority.
Encourage all levels of government, domestically and globally, to take appropriate and lawful action to contain an outbreak within the borders of their community, province, state, or nation. (5.3.1)
DOS and DHS, in coordination with DOT, DOC, HHS, Treasury, and USDA, shall work with foreign counterparts to limit or restrict travel from affected regions to the United States, as appropriate, and notify host government(s) and the traveling public. (126.96.36.199)
Where appropriate, use governmental authorities to limit non-essential movement of people, goods, and services into and out of areas where an outbreak occurs. (5.3.2)
The deployable number of officers and agents with delegated customs authority within these border agencies has grown since the Department of Homeland Security was created in 2003. This growth provides an expanded team of available resources with the now cross-designated immigration officers and agents. However, it remains a very limited resource for the enormous mission with the inadequate public health preparedness resources provided to the federal agencies. With the historical increase in illegal southern border entries in 2021 and 2022, the availability of customs officers shall be even more limited to handle this additional and unique duty for CDC on the behalf of the federal government.
The availability to execute actual quarantine detention orders and operations may be more challenging than expected with the inability of customs officers to depart from their day jobs for a rapidly emerging pathogen for early containment and control. Interdiction is difficult enough, but appropriate public health screening and lawful detention (for public health/quarantine or immigration concerns) are even more of a challenge for many reasons. This is especially problematic for the legitimate detention of the non-compliant and likely use of force issues necessary to enforce CDC quarantine mandates to protect the nation from an exploding pathogenic threat.
Implemented During COVID-19
Fortunately, not all of the Plan recommendations or preparedness appeared to be insufficient during the COVID-19 pandemic response. There were Plan actions and expectations that were utilized at some level during the COVID-19 pandemic.
DHS, DOS, and HHS, in coordination with DOT and USDA, shall issue travel advisories/public announcements for areas where outbreaks have occurred and ensure adequate coordination with appropriate transportation and border stakeholders. (188.8.131.52)
DHS and DOT, in coordination with DOS and Treasury, and international and domestic stakeholders, shall consider activating plans, consistent with international law, to selectively limit or deny entry to U.S. airspace, U.S. territorial seas (12 nautical miles offshore), and ports of entry, including airports, seaports, and land borders and/or restrict domestic transportation, based on risk, public health benefits, and economic impacts. (184.108.40.206)
It is unknown if the early successful responses were due to sufficient planning and preparedness or sheer necessity, but there were early achievements during the pandemic response. The challenge is to ensure that there shall be many more early successes in the next significant public health threat through common-sense planning and strong leadership. There shall be another pandemic in the future and likely sooner than later.
True Oversight and Coordination
The need for an empowered leader to oversee the federal government’s pandemic planning and preparedness strategy and activities has been a concern for many years. Its absence has been apparent to public and private sector observers to include influential outside organizations.
As documented in the Trust for America’s Health report, Ready or Not: 2021 Protecting the Public’s Health from Diseases, Disasters, and Bioterrorist, the nation was not prepared for a serious pandemic and lacked effective senior federal leadership and interdepartmental coordination. The report recommended the creation of “a White House Health Security Directorate, including senior advisors to the president with public health expertise on health security issues. This directorate would oversee the national biodefense strategy and all interagency emergency responses.” The Trust for America’s Health was not alone.
Despite having an existing pandemic strategy and plan, the United States was still unprepared to effectively respond to COVID-19.
The findings were similar to those in the Bipartisan Commission of Biodefense’s (previously known as the Blue Ribbon Study Panel on Biodefense) 2021 report, Biodefense in Crisis, Immediate Action Needed to Address National Vulnerabilities. That follow-up report identified the apparent results of national leaders and policymakers failing to consider and implement the 33 recommendations and 87 action items that the Commission outlined in its 2015 report, A National Blueprint for Biodefense: Leadership and Major Reform Needed to Optimize Efforts. According to the Commission, many of their recommendations and actions remained partially or completely unaddressed in 2021 after the arrival of the COVID-19 pandemic. With the other critical observations, the Commission stressed the insufficient federal government leadership issue in their 2021 report.
Our Commission strongly believes that one federal department cannot tell other departments and agencies what to do, especially in a critical area of responsibility like biodefense. The stalled execution of the National Biodefense Strategy demonstrates what we believed to be true: only the White House can direct all parts of the federal government to work together to defend the Nation against biological threats. Direction must come from someone occupying a position with the imprimatur of the President and the authority to act on the President’s behalf. (p. 7)
The Commission created and maintained an interactive webpage to monitor and update the recommendations and action items to encourage focus and progress. This proactive measure was an initiative designed to place emphasis on the recommendations and action items for prioritization and avoid needing to wait years for another future report to share status conditions or a possible lack of progress.
The two actions for institutionalizing the oversight responsibility with the vice president’s office to ensure that biodefense would be addressed by every administration, at the highest levels, and with adequate access to the president remained labeled as crisis actions. As of June 2022, the Commission reported that only three of the action items were completed and six remained as crisis actions. Partial action was reportedly taken for 56 action items with no action for 22 of them.
Use the Foundation
Many pandemic-related strategies, plans, authorities, and regulations existed across the federal government. However, the operational plans and sustained coordination appeared to wane over time with competing priorities, diminishing interest, or willful neglect.
The federal government was expected to release a new National Biodefense Strategy in the summer of 2022. The updated national strategy was intended to more clearly describe responsibilities, goals, and deadlines to address confusion and governmental infighting for pandemic response. The new National Biodefence Strategy would reportedly build upon the recent high-level American Pandemic Preparedness Plan (2021). An enhanced focus on unified leadership, authority, and action would be greatly beneficial along with a thoughtful and detailed implemented federal plan – possibly utilizing the 2006 Plan as a foundation for a whole-of-government approach.
As the nation continues to recover from the COVID-19 pandemic, the Strategy and Plan can provide a foundation to develop an updated and broader national strategy for the future, incorporating the most important priorities and mandates of the National Biodefence Strategy and National Strategy for Biosurveillance into one superseding strategy for the nation. The many common-sounding and overlapping strategies can often provide more confusion than focus on this most critical mission.
With the establishment of one designated and empowered leader with dedicated authority and influence to ensure that departments and agencies adopt and maintain their focus and capabilities for the next serious public health threat, the national security of the country would likely improve. The leader must be truly enabled to compel a coordinated effort for distinctly defined priorities and goals that are implemented, maintained, and evaluated over time.
There was an established pandemic strategy and plan in place to better prepare and protect the nation. The current Strategy and Plan can be utilized as a foundation to develop the next strategy and plan incorporating other public health and biodefense strategies along with the lessons learned from COVID-19. Without the development and implementation of an updated comprehensive strategy and plan, the nation shall likely relive the failures during the next pandemic. National strategies are vital, but their implementing plans are critical.
Important note: A pandemic such as COVID-19 may be considerably less concerning than a possibly much more serious bioterror or biowarfare attack utilizing a novel or enhanced pathogen – one with significantly greater transmission, morbidity, and mortality rates than SARS-CoV-2