Several events in the past decade sharpened congressional interest in the nation's ability to track and respond to health threats. Key incidents include the airline and anthrax attacks in 2001, Hurricane Katrina in 2005, and the H1N1 influenza ("flu") pandemic in 2009. In 2010, the United States rendered aid following the devastating earthquake in Haiti by, among other things, airlifting critically injured victims to the U.S. mainland. Residents of southern states experienced a massive oil spill in the Gulf of Mexico. Each of these incidents challenged existing incident response mechanisms, reminded policymakers of known gaps, and unmasked gaps that had theretofore gone unnoticed. Three important principles color the issues in public health and medical emergency management. First, pre-incident (or preparedness ) and post-incident (or response ) functions are very different. At each level of government, these functions involve different legal authorities, leadership roles, organizational structures, and funding mechanisms. Generally, during an incident, certain conditions must be met before a jurisdiction can implement response activities or access funds reserved for that purpose. Second, states and localities, rather than the federal government, are the seats of most authority and responsibility for the oversight of both health care and emergency management. For example, state laws generally authorize governors to order and enforce the evacuation of residents in emergency situations. Except under extraordinary circumstances, the federal government generally does not dictate the conduct of either health care or emergency management activities to state or local officials, or to health care providers. The federal government can, however, attach conditions to the expenditure of federal grant funds, in furtherance of national goals. Finally, while most public health functions—broad, population-based programs, such as restaurant inspections to ensure food safety—are inherently governmental, the nation's health care system—which delivers professional health care services to individuals—is primarily private and for-profit. Providers and facilities operate in an increasingly competitive marketplace in which emergency planning is not always seen as a necessary expense. For example, hospitals may be reluctant to maintain empty beds or to stockpile costly medical products to be ready for incidents that may not occur. In 2006, the 109 th Congress established or reauthorized relevant programs and activities, principally in the Departments of Health and Human Services (HHS) and Homeland Security (DHS), responding to problems identified during prior incidents. Appropriations authority for many of these programs and activities has expired or expires at the end of FY2011, and the 112 th Congress may consider reauthorization. Given the current budgetary climate, spending for public programs, including emergency management programs, may be significantly constrained. Under the circumstances, Congress may be interested in approaches to improve the efficiency of incident response mechanisms, to enhance the integration of the private sector in planning and response activities, to fully leverage routine capabilities for incident response, and to strengthen program accountability, among other things. This report, which will be updated as needed, summarizes key issues in the preparedness for and response to domestic, civilian public health and medical incidents, citing other CRS reports and additional sources of information. The 109 th Congress enacted two comprehensive laws affecting public health and medical preparedness and response. The Pandemic and All-Hazards Preparedness Act (PAHPA, P.L. 109-417 ), passed in 2006, established or extended programs for public health emergency preparedness and response activities in HHS, and established the Biomedical Advanced Research and Development Authority (BARDA) to spur the development of medical countermeasures. The Post-Katrina Emergency Management Reform Act of 2006 (PKEMRA, Title VI of P.L. 109-295 ) reorganized DHS and, within it, the Federal Emergency Management Agency (FEMA). PKEMRA also codified the position of DHS Chief Medical Officer, with primary responsibility within DHS for medical issues related to natural and man-made disasters and terrorism. Appropriations authority for a number of activities last reauthorized in PAHPA has expired, or will expire at the end of FY2011, and the 112 th Congress may consider reauthorization. Activities with expired or expiring appropriations authority include, among others, state grants for public health and hospital preparedness; the Strategic National Stockpile (SNS) of drugs and medical products; the National Disaster Medical System (NDMS), a cadre of rapid-response teams; and the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), a national database of volunteer health workers. In addition to programs with finite appropriations authority, Congress may also examine a number of permanent authorities. These include, for example, the authority of the HHS Secretary to declare a public health emergency, and to access a special fund for response purposes; authorities of the HHS Secretary or the Commissioner of the Food and Drug Administration (FDA) to ensure the safety of foods and medical products; and authorities of the President to declare an emergency or a major disaster and provide specified forms of assistance pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act (the Stafford Act). DHS has not operated under an authorization bill since it was originally established in 2003 ( P.L. 107-296 ). Past Congresses have considered, but not enacted, homeland security authorizations bills. Representative Peter King, chairman of the House Committee on Homeland Security, has said he intends to introduce such a bill in the 112 th Congress. For public health and medical preparedness and response, the roles and responsibilities of principals in HHS and DHS have shifted in past years. The 109 th Congress provided some clarity, but refinement of these roles and responsibilities is likely to continue for some time to come. Pursuant to PAHPA and PKEMRA, applicable activities in DHS are led by the DHS Chief Medical Officer (CMO), and in HHS by the HHS Assistant Secretary for Preparedness and Response (ASPR). PKEMRA provided that the DHS CMO "shall have the primary responsibility within the Department for medical issues related to natural disasters, acts of terrorism, and other man-made disasters," while PAHPA provided that the "Secretary of [HHS] shall lead all Federal public health and medical response to public health emergencies and incidents " (emphasis added). Hence, the Secretary of Homeland Security coordinates all federal emergency and disaster response activities; the DHS CMO coordinates both preparedness and response activities for public health and medical care, but only within DHS; and the Secretary of HHS, through the ASPR, leads all federal public health and medical response activities, under the overall leadership of the Secretary of Homeland Security. The Government Accountability Office (GAO) noted, in the context of pandemic flu planning, that "these federal leadership roles … involve shared responsibilities, and it is not clear how these would work in practice." GAO has recommended, among other things, that that DHS and HHS conduct training and exercises to ensure that federal leadership roles are clearly defined and understood. Federal incident response activities are coordinated according to the National Response Framework (NRF), an "all-hazards" response plan published by DHS. Public health and medical response activities (under the leadership of HHS) are laid out in an annex to the plan called Emergency Support Function #8 , or ESF-8. These activities, at the federal, state, and local levels, are commonly referred to as ESF-8 activities. (The NRF replaced the earlier National Response Plan, incorporating lessons from the flawed response to Hurricane Katrina. ) Nonetheless, some leadership gaps and conflicts remain in ESF-8. In addition to the interrelated roles of the HHS ASPR and the DHS CMO discussed above, there are concerns about a lack of leadership clarity for responder health and safety (see " The Health and Safety of Disaster Responders "); emergency sheltering; mass fatality management; and mental health services, among others. PAHPA requires the HHS Secretary to publish a comprehensive, all-hazards national public health and medical response strategy and implementation plan (the "National Health Security Strategy," or NHSS), beginning in 2009, and quadrennially thereafter. The NHSS is to include a process for achieving several specific preparedness goals enumerated in the statute. HHS published the first NHSS in December 2009, saying that national health security is a key element in achieving broader national security objectives. The NHSS states that it is designed to achieve two overarching goals: (1) build community resilience, defined in the NHSS as the sustained ability of communities to withstand and recover—in both the short and long terms—from adversity, and (2) strengthen and sustain health and emergency response systems. Also, the NHSS outlines approaches to better integrate routine and emergency capabilities, in order to improve the health system's responsiveness despite resource constraints. The 112 th Congress may be interested in reviewing the NHSS and monitoring the status of its implementation. The 112 th Congress may consider the adequacy of permanent authorities of the HHS Secretary for responding to public health threats, including authority to declare a public health emergency and the expanded authorities that flow from it. Members of Congress may also consider how HHS funds any of its disaster response activities that are not reimbursable by FEMA under the Stafford Act. Although the HHS Secretary has authority for a "no-year" Public Health Emergency Fund (i.e., funds are available until expended), Congress has not appropriated monies to the fund since FY1999, and there are no monies in the fund at this time. Also, it is not clear that a flu pandemic or bioterrorism incident would qualify as a major disaster under the Stafford Act. The definition of major disaster in the law does not explicitly include or exclude infectious diseases, and past interpretations of the provision's applicability to bioterrorism and naturally occurring infectious diseases have varied.