The National Response Framework consists of a base document and two types of annexes—the Emergency Support Function Annex and the Support Annex. The 2014 Quadrennial Defense Review notes the importance of DOD’s role in protecting the homeland and supporting civil authorities in mitigating the effects of natural disasters such as pandemics. DOD works closely with other federal agencies to coordinate the federal response to address the threat of pandemics and other types of incidents. Under the National Response Framework, Emergency Support Function (ESF) #8, Public Health and Medical Services Annex, HHS, DHS, and DOD have specific roles and responsibilities to support civil authorities and coordinate response efforts with other federal agencies to address public health and medical disasters. Department of Health and Human Services. HHS, through its Assistant Secretary for Preparedness and Response, leads all federal public health and medical responses to public health emergencies and other incidents covered by the National Response Framework and coordinates with other departments and supporting agencies to accomplish this mission. Several of its key functions under ESF #8 include activating the National Disaster Medical System as necessary to ensuring the proper disposal of contaminated products and the decontamination of affected food facilities in order to protect the public health; coordinating public health and medical support, patient evacuation, and movement requirements with other primary and supporting departments, agencies, and government authorities throughout the incident; and coordinating with support agencies—such as DOD—when an incident requires federal assistance above and beyond its interagency mechanisms. Department of Homeland Security. DHS serves as the lead for interagency coordination and planning for emergency response. Several of its key functions under ESF #8 include assisting in providing information and liaison with emergency arranging transportation to evacuate patients who are too seriously ill or otherwise incapable of being evacuated in general evacuation conveyances; and arranging for the use of U.S. Coast Guard aircraft and other assets in providing urgent airlift and other transportation support. Department of Defense. DOD is responsible—subject to the availability of resources and the direction of the President or by approval of the Secretary of Defense—for providing support functions and supplementing civil authorities’ resources in response to public health and medical disasters. Several of its key functions under ESF #8 include providing military personnel for casualty clearing or staging and other providing support for the evacuation of patients to locations where hospital care or outpatient services are available; and providing military personnel to assist in the protection of public health by providing, for example, food, water, wastewater removal, solid waste disposal, hygiene, and vector control. (See appendix III for a more complete discussion of these federal agencies’ roles and responsibilities in support of the National Response Framework through ESF #8.) DOD typically provides support in response to a formal request for assistance (RFA) from other federal departments or agencies and—in cases where response is needed immediately—from state, local, or tribal and territorial governments. Support provided in response to such RFAs may help these civil authorities to prepare for, prevent, protect against, respond to, and recover from domestic incidents, including terrorist attacks and major disasters. DOD assets are usually requested if other federal, state, local, and tribal assets are not available. However, DOD resources are not typically required to respond every domestic incident. DOD resources can be made available to support disaster response through a presidential declaration. For example, according to the Robert T. Stafford Disaster Relief and Emergency Assistance Act (commonly referred to as the Stafford Act), when a state’s capabilities and resources are overwhelmed and the President declares an emergency or disaster, the state Governor can request assistance from the federal government. The Stafford Act gives the President the authority to establish a program of disaster preparedness and response support. Homeland Security Presidential Directive-5 designates the Secretary of Homeland Security as the principal federal official for domestic incident management. Defense resources are committed only after the primary agency submits a request for assistance, through proper channels, and the President or Secretary of Defense authorizes DOD to provide support. Such support may help civil authorities prepare for, prevent, protect against, respond to, or recover from domestic incidents—including pandemics and major disasters. Figure 1 illustrates how DOD’s support is obtained through the current RFA process following a presidential declaration of a major disaster or emergency. FEMA currently is developing guidance that will include a standardized mission assignment process, which will replace the current mission assignment process. According to FEMA officials, they have not yet determined when a final version of the guidance will be issued. Defense support of civil authorities also can be requested and provided when there has been no presidential declaration. DOD Directive 3025.18, Defense Support of Civil Authorities, authorizes immediate response authority for providing support. This can be invoked when DOD is requested to respond to an incident under imminently serious conditions when time does not permit approval from a higher authority. Upon request from a civil authority, DOD officials may employ resources under their control for up to 72 hours, subject to any supplemental direction provided by higher headquarters, to save lives, prevent human suffering, or mitigate great property damage within the United States. Immediate response authority does not permit actions that would subject civilians to the use of military power that is regulatory, prescriptive, proscriptive, or compulsory. In addition, the Economy Act permits one federal agency to request the support of another federal agency, provided that the requested services cannot be obtained more cheaply or conveniently by contract. Under this Act, a federal agency with lead (primary) responsibility may request the support of DOD without the presidential declaration of emergency required by the Stafford Act. Finally, DOD may provide health services—as a supporting agency to HHS—in accordance with the National Disaster Medical System, following HHS’s declaration of a public health emergency. According to DOD guidance, for the purpose of activating the National Disaster Medical System, a public health emergency may include a public health emergency declaration by the Secretary of Health and Human Services or a declaration of a disaster or emergency pursuant to the Stafford Act. DOD has developed guidance and plans at various levels to direct its efforts to provide assistance in support of civil authorities in the event of a domestic outbreak of a pandemic disease. The Department of Defense Global Campaign Plan for Pandemic Influenza and Infectious Diseases 3551-13, issued in 2013, provides overarching guidance to DOD and the military services on how to plan and prepare for a pandemic outbreak. According to a DOD official, other DOD guidance—such as the Guidance for the Employment of the Force—directs U.S. Northern Command and U.S. Pacific Command to be prepared to provide defense support of civil authorities and the Joint Strategic Capabilities Plan specifies how this should be accomplished. According to the Global Campaign Plan, U.S. Northern Command is designated by DOD as the global synchronizer for influenza pandemic and infectious disease plans. In this role, U.S. Northern Command is responsible for providing strategic planning guidance for the department’s efforts to prepare for and respond to pandemic diseases. This guidance directs the geographic combatant commands and the military services to develop influenza pandemic and infectious disease plans and to coordinate and synchronize those plans with the Global Campaign Plan. As the lead synchronizer, U.S. Northern Command is responsible for ensuring that plans developed by the combatant commands and military services are aligned with the Global Campaign Plan in areas such as biosurveillance and disease monitoring and sharing best practices; among other responsibilities. U.S. Northern Command’s CONPLAN 3591-09 Response to Pandemic Influenza provides guidance to U.S. Northern Command decision makers on identifying the capabilities and forces needed to maintain the defense of the homeland while limiting the long-term effect of a pandemic on the security, health, and safety of the nation. This plan explains how U.S. Northern Command would respond to a pandemic outbreak by identifying capabilities—such as personal protective equipment and medical countermeasures—to prevent human- to-human transmission. The plan also includes key assumptions about how a pandemic could affect DOD’s ability to provide homeland defense. For example, the plan states that an absentee rate of 40 percent among DOD personnel, occurring at the height of a severe pandemic wave, could affect U.S. Northern Command’s ability to protect the homeland and result in fewer resources being available to support requests for support from civil authorities. The Homeland Defense mission can be performed only by DOD and thus is its first priority. The pandemic response ultimately is the responsibility of state, local, and tribal and territorial authorities, and with the support of other federal agencies. The plan states that an influenza pandemic would cause unprecedented illness, death, and disruption to normal patterns of life, resulting in emotional, psychological, spiritual, and physical pressures on U.S. Northern Command’s forces. The plan states that the combatant command will mitigate the risk of a pandemic by synchronizing planning within the department and with other elements of national power (i.e., diplomatic, informational, military, and economic) to support U.S. government strategies and objectives embodied in the National Strategy for Pandemic Influenza. In addition, the plan states that the combatant command will coordinate resources with federal departments and agencies to ensure that preparedness and response efforts are prioritized and resourced to respond to a pandemic. Other combatant commands also have developed plans for providing support in the event of a pandemic. According to an official from U.S. Northern Command, currently all six of the geographical combatant commands have pandemic influenza and infectious disease plans for their assigned areas of responsibility. The remaining three ‘functional” combatant commands, which include the U.S. Special Operations Command, have not developed pandemic influenza and infectious disease plans because they operate in support of and within the supported geographical combatant command’s area of responsibility.