The U.S. Government’s Approach to Health Security: Focus on Medical Campaign Activities

DOWNLOAD PDF

The U.S. Government plans, conducts, supports, and participates in activities that reinforce national interests. These interests perpetuate an international order underpinned by stable democratic governments and regional security. One critical component of national stability is the capability to protect citizens from internal and external threats. This capability normally requires a nation to draw upon its citizenry to populate internal forces responsible for providing security; therefore, a healthy populace is a necessity. With the U.S. Government’s increasing responsibility as a security provider and its political emphasis on health security, the U.S. military will undoubtedly be expected to have a larger role in support of health security objectives. While natural or manmade threats to human health can lead to illness or injury, illness transmitted by proximity between humans remains among the foremost dangers to human health, international stability, and the global economy. In other words, health security is crucial to U.S. national security.

For purposes of this analysis, U.S. health security focuses on human health and is sought and maintained through successful public health and global health activities. While “public health” focuses on domestic or national human health issues, “global health” focuses on international human health issues that are linked to U.S. domestic security. For an overview of U.S. health security responsibilities and the role of the U.S. military in providing medical aid, this discussion is separated into four sections that capture analysis based on documents, informal discussions, and military briefings: the history of U.S. health policy through legislative actions and international engagements, health policy as articulated in Federal department strategies and other executive branch documents, medical campaign activities executed under the U.S. Code, and recommendations for strengthening U.S. Government health security efforts.

Legislative Actions and International Engagement

U.S. legislative history and international agreements capture methods that attempt to address modern health security concerns. The government’s public health infrastructure originates from early congressional legislation that, just 9 years into the Nation’s existence, created the U.S. Public Health Service to treat those who served the country at sea.1 Fifteen years after the Civil War, the American Red Cross was created to provide medical treatment for those citizens who served in uniform. Following World War I, an international League of Nations was created2 that administered a separate Health Organization to address prevention and control of certain diseases.3 The League and Health Organization eventually became the United Nations (UN) and World Health Organization (WHO), respectively, both of which the United States provides humanitarian assistance to upon request. During World War II, the U.S. Congress passed the Public Health Service Act that produced an entity now known as the U.S. Department of Health and Human Services (DHHS).4 Since then, the United States has steadily increased economic and social development assistance to foreign nations that, in turn, contributed to their own public health systems.

In 1949, the United States became a signatory to a set of international treaties known as the Geneva Conventions and Protocols. One subject included protecting civilian victims of armed conflict and internal violence.5 Further enhancements addressed “protection of civilians” beyond hostilities to include accessibility to essential services and medical care. Over the next decade, these treaties influenced the United States to support more requests abroad for military assistance. In 1961, Congress passed the Foreign Assistance Act (FAA) to better assist partner nations with security challenges, which eventually led to public and global health support. One tenet distinguished military assistance from humanitarian and development assistance while another created the U.S. Agency for International Development (USAID), which carries out U.S. global health policy development, coordination, and execution.6 In 2005, the United States became a signatory to the WHO’s International Health Regulations (IHR), a legally binding agreement among 196 state parties, which obligates member states to develop and maintain international public health threat detection, assessment, notification, and response capabilities.7 Under the IHR, the United States globally assists other nations to ensure that health security capabilities are in place and procedures followed.8 Additionally, the Global Health Security Agenda (GHSA) and the Global Health Security Initiative (GHSI) accelerate international progress against infectious diseases and chemical, biological, radiological, and nuclear (CBRN) exposure, respectively.

With such maturation in U.S. health policy and support for human rights, a more focused national direction on health security has emerged. The following discusses Presidential and department strategies on health security policy.

The Executive Branch

Offices, departments, and independent agencies make up the executive branch; however, our focus is on departments with Presidential-appointed department heads that implement U.S. policy. The President’s Cabinet today includes 15 department heads known as Cabinet Secretaries. A smaller group of appointed advisors known as the National Security Council (NSC) is a forum used by the President to consider national security and foreign policy matters.9 One policy document that links executive policy to department activities is a national strategy. For security policy, the President’s National Security Strategy (NSS) connects U.S. policy goals managed by the NSC to objectives on security matters.10 Subsequently, the U.S. National Health Security Strategy (NHSS) issued by DHHS further articulates health security policy objectives that are linked to NSS objectives. As a result, health security roles within the executive branch are further defined.

The President also articulates policy through executive orders. One order that provides the President’s position on national security matters is called a Presidential Directive. In the last 20 years, five directives set conditions that impact health security. In 1996, President Bill Clinton signed a directive on emerging infectious diseases that increased U.S. surveillance, training, research, and response. It also directed the development of the Department of Defense’s (DOD) Global Emerging Infections Surveillance and Response Program.11 In 2009, President Barack Obama issued a directive on the implementation of the national strategy for countering biological threats that focused on global health security promotion with other nations to prevent, detect, and respond to infectious disease.12 Shortly thereafter, the President issued a directive named U.S. Global Development Policy,13 which elevated development efforts to be on par with diplomacy and defense.14 Another, National Preparedness,15 enhanced the Department of Homeland Security (DHS) and its National Response Framework (NRF) to better synchronize a whole-of-government response to a spectrum of security threats that include health security.16 More recently, Security Sector Assistance was issued to promote partner-nation support of U.S. interests to include cooperation on humanitarian efforts.17 All of these directives impact health security strategy development. The following department overviews capture Federal health security efforts in three cascading categories: significant, additional, and remaining.

Significant Efforts

Two departments play significant roles in achieving U.S. health security objectives: the Department of State and DHHS. State manages foreign affairs for the President and persuades other nations to support U.S. international efforts that impact global economic stability, regional security, and national health security. Two strategic documents that provide guidance to organizational efforts are the non-congressionally mandated Quadrennial Diplomacy and Development Review and the Department of State and USAID Joint Strategic Plan.18 For the purposes of this discussion, the U.S. Government development agency responsible for administering civilian foreign aid known as USAID, although considered a separate government agency, is categorized as an entity here under State as they both share one Cabinet Secretary.19

For disaster relief missions, State regional bureaus take the diplomatic lead due to their regional expertise. However, USAID’s Office of U.S. Foreign Disaster Assistance (OFDA) administers government responses that include medical aid. Generally, when a foreign disaster is declared or humanitarian crisis emerges, the President selects USAID as the operational lead for coordinating the government response. Although not a member of the President’s Cabinet, USAID’s administrator is elevated to Cabinet-level member status separate from the Secretary of State and invited to NSC meetings when development and global health issues are concerned.20 For domestic response, State manages potential international contributions of support.

State also manages diplomatic efforts that result in foreign assistance to other nations including countering threats to human health. One effort is focused on global health, which is identified as the largest component of U.S. long-term development assistance.21 Within global health is an integrated approach to improve global health conditions known as the Global Health Initiative (GHI). Distinct from the GHSA and GHSI international agreements, USAID-led GHI implementation includes the defense against threats toward population health,22 fight against communicable diseases transmitted by contact, and support of international health advances.23 Separate from USAID efforts, State manages the U.S. HIV/AIDS effort via the President’s Emergency Plan for AIDS Relief.24

DHHS is the other department that pursues U.S. health security objectives.25 Per its Strategic Plan and Global Health Strategy, DHHS cooperates with scientists worldwide to diagnose, prevent, and control the spread of disease.26 Additionally, DHHS produces the congressionally mandated quadrennial NHSS27 that guides health consequence mitigation of large-scale emergencies, provides strategic direction, and streamlines health security approaches.28 DHHS information-sharing, disease surveillance, and laboratory research capabilities also play significant roles in its illness mitigation strategy.

In support of U.S. global efforts, DHHS provides assessments, disease control mitigation, crisis and disaster response, and CBRN support.29 Via its components, the Centers for Disease Control and Prevention (CDC) personnel, National Institutes of Health laboratory researchers, and Food and Drug Administration scientists support responses to prevent further consequences to human health.30 Moreover, under GHSA and GHSI arrangements, the CDC assists partner nations in health surveillance against emerging infectious diseases, combats injuries from CBRN events and infectious diseases such as pandemic influenza with immunizations,31 manages the President’s Malaria Initiative, participates with DOD in informal international partnerships such as the Global Outbreak Alert and Response Network and the Laboratory Response Network,32 and actively engages in global partnerships to reduce the impacts of HIV/AIDS.

For domestic activities, DHHS leads U.S. efforts to protect against public health threats and provide countermeasures for mitigation, as well as contributes to crisis response.33 As such, DHHS conducts public outreach as well as maintains the federally coordinated National Disaster Medical System (NDMS). This system encompasses out-of-hospital medical care during crisis response to disaster stricken areas, patient movement for those unable to transport themselves, and treatment at participating hospitals in unaffected areas.34 DHHS activates the NDMS under its own authorities or through the NRF where it is delegated authority by DHS to be the operational lead for Emergency Support Function #8, Public Health and Medical Services.35 Furthermore, DHHS leads the reception of evacuees in the United States, administers domestic quarantine stations at U.S. ports of entry in support of DHS,36 and maintains a unique force of 6,700 uniformed but nonmilitary health professionals known as the U.S. Public Health Service (USPHS) corps.37 In times of national emergency, the corps can deploy with other U.S. departments.38 DHHS also oversees a domestic network of volunteers known as the Medical Reserve Corps program that strengthens public health systems and improves preparedness, response, and recovery capabilities.39 Furthermore, CDC Epidemic Intelligence Service personnel identify global causes of disease outbreaks, recommend prevention and control measures, and implement strategies to protect people from health threats.40

Additional Efforts

The following departments make substantial contributes to U.S. health security: DHS; DOD; and the Departments of Agriculture, Commerce, Energy, and Treasury. DHS guidance is provided in the DHS Strategic Plan41 and the congressionally mandated Quadrennial Homeland Security Review.42 DHS core responsibilities are to provide domestic security and coordinate domestic Federal crisis response to include establishing Federal response structures, delegating domestic emergency response to the Federal Emergency Management Agency (FEMA), maintaining a maritime domain capability through the U.S. Coast Guard,43 and supporting medical cooperative efforts through the NDMS with DHHS and other interagency stakeholders.44 However, DHS does play a supporting role in global health efforts through cross-border protection to include U.S. airports and seaports.45

DOD supports health security efforts primarily through its military workforce. Key strategic documents include the Defense Security Guidance,46 the National Military Strategy,47 and the congressionally mandated Defense Strategic Review (formerly known as the Quadrennial Defense Review).48 In support of U.S. capacity-building activities abroad, DOD contributes to engagement and prevention programs, surveillance and response systems, and a network of overseas research laboratories. DOD also supports civil authorities through medical research, preparation, surveillance, and response to biological threat requests. In addition, DOD provides military medical support to the NDMS49 as well as preplanned domestic medical civic action events with local communities through its Innovative Readiness Training program.50

The Department of Agriculture’s strategic plan addresses animal health, public health, plant health, environmental health, and improved access to nutritious food.51 This includes participation in activities abroad with DOD on provincial reconstruction efforts, countering terrorism, and managing animal disease control.52 The Department of Commerce’s strategic health objectives focus on fostering healthy and sustainable marine resources such as fish stocks, habitats, and ecosystems.53 It also administers a nonmilitary but uniformed response service54 known as the National Oceanic and Atmospheric Administration,55 which interacts with the U.S. Navy via the Global Fleet Station sea base program.56 The Department of Energy’s57 non-congressionally mandated Quadrennial Energy Review58 and Quadrennial Technical Review59 both articulate strategies to prevent the proliferation of weapons of mass destruction abroad,60 address threats to public health and the environment from energy transmission,61 and pursue the cleaning up of legacy nuclear waste locations.62 Also the Treasury Department63 uses its significant global reach to fund immediate needs that may include medical activities based on U.S. approval and mitigate emerging threats against the U.S. and global economies by relieving or enforcing sanctions.64

Remaining Efforts

A couple of remaining departments maintain significant capabilities to address domestic public health concerns but have minimal, if any, equity in support of global health efforts.65 The Department of Transportation administers a National Defense Reserve Fleet, Ready Reserve Force, and Civil Reserve Air Fleet that can augment the transportation of military Services to potentially support public health activities.66 Moreover, the Department of Veteran’s Affairs (DVA) provides health professionals and incident-related medical care via Federal medical stations and coordinating centers to care for those with injuries in support of NDMS hospital activation.67

As U.S. Government departments continue to develop their own strategies to achieve health security objectives, the future is uncertain on how they will plan for a robust international workforce response. Currently, USAID-led foreign disaster relief is effective for routine disasters but additional progress is needed to better coordinate U.S. humanitarian assistance for catastrophes with cascading effects to public infrastructure (for example, the loss of electrical power grids and exposure to chemical and radiological events).68 One solution is to use the domestic NRF as a framework. Such a framework could produce a mechanism that would be useful due to the fact that most foreign governments are not prepared to respond to out-of-the ordinary, severe catastrophes that overwhelm local and regional response capacity. In Haiti, for example, relief efforts were hampered as responders, including U.S. forces, operated in a severely disrupted environment. The ability of Haiti’s leadership to prioritize and coordinate U.S. humanitarian assistance was disabled and healthcare infrastructure to be supported was destroyed. Future demands on the United States for more coordinated relief and lifesaving assistance will continue to be expected, placing more burdens on the U.S. Government departments that make up the NSC system to prepare and contribute.

Furthermore, while departments develop their own strategies, they should also keep a watchful eye on how they are portrayed in joint doctrine—the core foundation of military workforce best practices. Relevant Joint Publications (JPs) for this discussion include JP 4-02, Joint Health Services, JP 3-07, Stability, JP 3-08, Interorganizational Cooperation, JP 3-20, Security Cooperation, JP 3-28, Defense Support of Civil Authorities, JP 3-29, Foreign Humanitarian Assistance, and JP 3-57, Civil Military Operations.

Medical Campaign Activities

DOD leads or supports Federal efforts that shape operational environments to set, establish, reestablish, or maintain interaction with political entities. One effort is the provision of U.S. humanitarian assistance that includes medical, general engineering, food and water, educational, professional exchange, and disaster preparation activities. DOD contributions underpin these efforts known in joint doctrine as maintaining stability or building capacity abroad via foreign humanitarian assistance (FHA), providing crisis response support through domestic defense support to civil authorities (DSCA), and delivering foreign disaster relief under FHA. While there are many terms that describe DOD medical contributions to U.S. medical efforts (medical civil-military or stability operations, global health or partnership engagement, public health services, health diplomacy, disease surveillance, security assistance or cooperation, etc.), this discussion refers to those contributions as “medical campaign activities.” Medical campaign activities are DOD specific, unlike the categorization of U.S. Government or other entity medical efforts or activities. Selecting a label is not to minimize the importance of the mission, operation, activity, or task; it is used only to provide clarity for those in uniform who participate in or implement it. The following articulates medical campaign activities within Title 10 and Title 22 legal authorities of the U.S. Code.

Title 10 of the U.S. Code

Title 10 is a compilation of permanent legal authorities that the Secretary of Defense uses to authorize federalized military forces to conduct military missions in support of U.S. efforts including humanitarian mission preparation and response. For this discussion, DOD medical campaign activities fall under three categories: disaster relief, byproduct of conflict, and force health protection. While it is important to acknowledge that DOD provides for the well-being of military personnel and supports U.S. stabilization efforts that sets or reestablishes interaction with political entities, the following focuses on the first mentioned category of DOD disaster relief via combatant commander oversight.

For crisis situations abroad, USAID/OFDA generally leads the U.S. response when disaster relief is requested of the Federal Government. In support of U.S. humanitarian assistance, DOD, with its sheer size, budget, and ready capabilities make it an attractive candidate for international aid requests; however, DOD normally contributes to less than 10 percent of all OFDA managed disaster relief.69 When DOD does contribute to FHA, its unique and time-sensitive capabilities deliver medical campaign activities mostly in the form of direct patient care, medical supplies transportation, and casualty evacuation generally funded by Overseas Humanitarian, Disaster, and Civic Aid. In 2010, DOD medical campaign activities in support of USAID-led Haiti earthquake disaster relief response efforts included immediate and urgent medical treatment by medical teams from the USNS Comfort.70 When the ship reached capacity, severely injured Haitian patients were evacuated to U.S. hospitals under the authority of the NDMS and were treated by DHHS and DVA personnel.71 In 2014, DOD conducted medical campaign activities to support the U.S. response to Ebola in Western Africa.72 These medical campaign activities included laboratory testing and oversight of Ebola treatment unit construction.73 DHHS/USPHS personnel cooperated with DOD to stabilize, mitigate, and prevent contagion74 through expeditionary medical system support and training of international health workers.75

When domestic Federal disaster relief assistance is requested, DHS/FEMA leads domestic coordination with DHHS managing the medical response. Medical campaign activities to DSCA includes restoring essential health services in collaboration with the state and local health entities.76 In support of 2005 Federal assistance to Hurricane Katrina victims, medical campaign activities included airlift operations and medical treatment in support of civilian organization efforts along the Gulf Coast.77 In support of 2012 Federal assistance to Hurricane Sandy victims, medical campaign activities conducted by preventive medicine personnel included testing the safety of food, water, and air in the storm-damaged areas where military personnel were sent to assist.78 DOD also approved FEMA’s request for transport of over 120 medical personnel to serve as augmentation for hospitals and nursing homes.79 Veterinarian services were also provided.

In noncrisis situations that include preparation, risk reduction, and building capacity, medical campaign activities generally focus on training U.S. forces and assisting in the development of or improving medical capacity of government entities. Medical campaign activities in foreign countries funded by Humanitarian and Civic Assistance include events that allow U.S. military medical professionals to practice on real patients to improve their skills.80 Geographic combatant commands conduct these preplanned medical readiness training exercises and dental or veterinarian exercises in conjunction with foreign Ministries of Health and Defense that impact people, livestock, and pets in distant regions and remote villages.81 Additionally, these activities bolster host-nation health service capabilities that in turn build local civilian population confidence in the delivery of government essential services. In 2015, DOD’s Continuing Promise and Pacific Partnership missions conducted FHA activities in 15 foreign nations across Central America and the Caribbean with nongovernmental organizations as well as Southwest Asia and the Oceana regions with allied nations, respectively. Medical campaign activities included over 142,000 patients treated in local ports and over 1,900 surgeries conducted aboard hospital ships.82

Other medical campaign activities abroad include risk reduction and building capacity programs, communicable disease prevention, infectious disease surveillance and response, an overseas research laboratory network,83 and academic courses taught by DOD institutions. On the domestic front, DOD conducts medical campaign activities in the form of preplanned civic events with local communities.

Title 22 of the U.S. Code

Title 22 is a compilation of permanent legal authorities that the Secretary of State uses to provide foreign assistance to partner nations. DOD components participation in activities authorized in the FAA and by the President that include health security. Per the FAA, U.S. foreign assistance provides a comprehensive list of assistance, some of which DOD personnel deliver for State.84 Within foreign assistance, elements such as security assistance, humanitarian assistance, and development assistance are codified in law.85

Formerly known as military assistance in the FAA, security assistance is the most profound way that DOD supports State in delivering foreign assistance. Most likely, the term security assistance was later adopted by Congress to lessen the appearance of the militarization of diplomatic efforts during the Cold War. Per the FAA, security assistance is defined as a group of planned programs authorized by law where the U.S. provides defense articles, military training, and other defense-related services, by grant, loan, credit, or cash sales to further national policies and objectives.86 Within U.S. security assistance programs, medical campaign activities range from medical training to medical equipment and donation of medical supplies. Prioritized by both State and DOD, DOD personnel administer medical campaign activities that fall within Foreign Military Sales (FMS), Foreign Military Finance (FMF), International Military Education Training (IMET), and the Global Peace Operations Initiative (GPOI). For FMS, military material is delivered to partner nations upon formal agreement (for example, first aid kits, warrior aid and litter kits, bandages, and medical equipment sets). Under FMF, funding includes defense article acquisition, provision of services, medical facility construction, and training to nations with weak economies87 (for example, in the 1990s the U.S. Government provided Egypt with tens of millions of dollars that went to constructing a 650-bed international medical center for the Egyptian military).88 Moreover, IMET funds the educational instruction by U.S. offices, employees, contract technicians, and contractors to foreign military students, units, and courses on a nonreimbursable (grant) basis that includes health security.89 Furthermore, GPOI funds certain activities that build partner country peacekeeping capacity and proficiency for the deployment of foreign militaries that include medical training to foreign forces that may deploy to UN peacekeeping operations.

As for State-managed U.S. Government humanitarian and development assistance, they do not normally involve military personnel. Per the FAA, humanitarian assistance is aid that meets humanitarian needs, including medicine, medical supplies, equipment, and education.90 U.S. Government development assistance is aid in support of another nation’s self-help efforts that are essential to successful long-term development.91 As DOD has no formal leadership role in the delivery of Title 22 humanitarian assistance or development assistance, it has been the view of some civilian-led organizations that certain long-term humanitarian or development-like Title 10 activities, which include medical campaign activities, mostly fall under traditional civilian-led responsibilities. To mitigate confusion, DOD is encouraged by these organizations to label humanitarian efforts as something other than humanitarian assistance and only provide support to U.S. development efforts.92

Conclusion

DOD medical campaign activities is a useful term to identify medical contributions within DOD activities to U.S. health security efforts and programs. In support of U.S. national interests, medical campaign activities are a core element of strategic competition and will continue to be planned for in support of DOD FHA activities to overall U.S. Government efforts. Abroad, medical campaign activities provide a good tool for not only mitigating threats to health security but also countering insurgencies that offer their own medical care to influence and control local civilian populations.93 At home, medical campaign activities provide immediate lifesaving assistance to U.S. state and local governments and build confidence in Federal government intentions.

Although medical campaign activities that defend against infectious disease efforts such as the Ebola virus are less common, involvement by the U.S. military most likely will increase considerably due to its robust logistics and rapid transportation and surveillance capabilities. In 2015, DOD conducted medical campaign activities in support of U.S. humanitarian assistance efforts to protect civilians from the Zika virus.94 With national direction on health security and missions of the U.S. military evolving, changes in joint doctrine should more clearly reflect the shift beyond force health protection toward the protection and medical treatment of civilians in multiple types of operating environments.

To more adequately address health security issues in the future, the following recommendations would be of value to assist the United States in improving health security response capabilities:

Congressionally mandate a Quadrennial Security Review to better coordinate a government approach to national security matters, including human health security, therefore forcing departments to plan for non-DOD workforce emergency and disaster relief packages.

Create a Presidential Directive for an International Response Force to assist in codifying a U.S. Government catastrophic coordination mechanism that will raise department priorities for development of a complex medical response capacity.

Create a Presidential Directive on Health Security to raise the priority for planning and importance of U.S. health security efforts expressed and implied in existing directives and strategic documents.

Identify non-DOD U.S. entities that can potentially execute existing DOD medical campaign activities and assist in the development of their capabilities to plan for and fill potential DOD health security capability shortfalls in future missions due to constrained budget environments and sequestration.

Encourage interorganizational participation in joint doctrine development to capture best practices and create awareness of extant non-DOD health security capabilities used in cooperation with DOD to further expose stakeholders to each other’s capabilities and systems.95 JFQ

Notes

1 An Act for the Relief of Sick and Disabled Seamen, 1 Stat. L., 605, 5th Cong., 2nd sess., July 16, 1798.

2 Derek Licina, “The Military Sector’s Role in Global Health: Historical Context and Future Directions,” Global Health Governance 6, no. 1 (Fall 2012), 4; League of Nations, Covenant of the League of Nations, April 28 1919, available at <www.refworld.org/docid/3dd8b9854.html>.

3 Iris Borowy, Coming to Terms with World Health: The League of Nations Health Organisation 1921–1946 (Frankfurt: Internationaler Verlag Der Wissenschaften, 2009), 57.

4 Public Health Service Act of 1944, Public Law 78-410, 78th Cong., 2nd sess., July 1, 1944.

5 International Committee of the Red Cross, Geneva Convention Relative to Protection of Civilian Persons in Time of War, August 12, 1949, 6 UST. 3516, 75 U.N.T.S. 287.

6 Foreign Assistance Act of 1961, Public Law 87-195, 87th Cong., 1st sess., September 4, 1961.

7 International Health Regulations (2005), 2nd ed. (Geneva: World Health Organization, 2008), available at <www.who.int/ihr/publications/9789241596664/en/>.

8 National Health Security Strategy and Implementation Plan (NHSS/IP) 2015–2018 (Washington, DC: Department of Health and Human Services, 2015), 30.

9 Barack H. Obama, Presidential Policy Directive (PPD)-1, Organization of the National Security Council System (Washington, DC: The White House, February 13, 2009).

10 National Security Strategy (Washington, DC: The White House, May 2010), 39.

11 William J. Clinton, Presidential Decision Directive NTSC-7, Emerging Infectious Diseases (Washington, DC: The White House, June 12, 1996).

12 Barack H. Obama, PPD-2, Implementation of the National Strategy for Countering Biological Threats (Washington, DC: The White House, November 23, 2009).

13 Barack H. Obama, PPD-6, U.S. Global Development Policy (Washington, DC: The White House, September 23, 2010).

14 Foreign Assistance Act of 1961, Public Law 94-161, 94th Cong., 1st sess., December 20, 1975. In 1993, President Clinton nominated the Director for the U.S. Agency for International Development (USAID) as the Special Coordinator for foreign humanitarian assistance and disaster relief; PPD-6.

15 Barack H. Obama, PPD-8, National Preparedness (Washington, DC: The White House, March 8, 2011).

16 Ibid.

17 Barack H. Obama, PPD-23, Security Sector Assistance (Washington, DC: The White House, April 5, 2013).

18 The first combined Department of State and USAID strategic plan was published in 2003.

19 Title 22 U.S. Code § 6592, Foreign Affairs Agencies Consolidation, Administrator of AID [the Agency for International Development] reporting to Secretary of State. For organizational purposes, under U.S. law, USAID falls under State.

20 Quadrennial Diplomacy and Development Review (Washington, DC: Department of State, July 2009), 115; PPD-6, 5.

21 FY 2014–2017 Department of State and USAID Strategic Plan (Washington, DC: Department of State, 2014), 23.

22 U.S. Global Health Policy, The U.S. Government Engagement in Global Health: A Primer (Washington, DC: The Henry J. Kaiser Family Foundation, January 2013), 20–25.

23 See Global Health Initiative, available at <www.ghi.gov>.

24 FY 2014–2017 Department of State and USAID Strategic Plan, 23.

25 Edwin K. Burkett, “Foreign Health Sector Capacity Building and the U.S. Military,” Military Medicine 177 (March 2012), 298.

26 The Global Health Strategy of the U.S. Department of Health and Human Services [DHHS] (Washington, DC: DHHS, October 13, 2011). See also “Strategic Goal 3: Advance the Health, Safety, and Well-Being of the American People,” available at <www.hhs.gov/strategic-plan/goal3.html>.

27 Public Health Service Act, Public Law 109-417 § 103, 109th Cong., 2nd sess., December 19, 2006, 120; see also National Health Security Strategy and Implementation Plan (NHSS/IP) 2015–2018.

28 See the National Health Security Strategy, Public Health Emergency, available at <www.phe.gov/Preparedness/planning/authority/nhss/Documents/nhss-ip.pdf>.

29 The Global Health Strategy of the U.S. Department of Health and Human Services, 10.

30 Strategic Plan FY 2014–2018 (Washington, DC: DHHS, March 2014).

31 JP 3-08, Interorganizational Coordination (Washington, DC: The Joint Staff, Revision First Draft), 173–174.

32 Ibid., 174.

33 Ibid., 171.

34 See the National Disaster Medical System, Public Health Emergency, available at <www.phe.gov/preparedness/responders/ndms/Pages/default.aspx>.

35 National Response Framework (Washington, DC: Department of Homeland Security, January 2008).

36 JP 3-08, 172.

37 Strategic Plan FY 2014–2018 (Washington, DC: DHHS, March 2014).

38 Committee on Oversight and Investigations, “Testimony from Rear Admiral Boris D. Lushniak on Update on the U.S. Public Health Response to the Ebola Outbreak,” November 18, 2014, available at <www.hhs.gov/asl/testify/2014/11/t20141118b.html>.

39 See the Medical Reserve Corps Program Web site, available at <https://mrc.hhs.gov/HomePage>.

40 See the Centers for Disease Control’s Disease Detectives, available at <www.cdc.gov/eis/diseasedetectives.html>.

41 Strategic Plan for Fiscal Years (FY) 2012–2016 (Washington, DC: Department of Homeland Defense, 2012).

42 Quadrennial Homeland Security Review (Washington, DC: Department of Homeland Security, June 18, 2014). See Homeland Security Act of 2002, Public Law 107-296 § 707, 107th Cong., 2nd sess., November 25, 2002, 154.

43 JP 4-06, Joint Mortuary Affairs (Washington, DC: The Joint Staff, October 12, 2011), VII-1.

44 See “Standard National Disaster Medical System Provider Memorandum of Agreement for Definitive Medical Care,” Public Health Emergency, available at <www.phe.gov/ndms/reimbursement/Documents/NDMS-Provider-MOA.pdf>.

45 Ibid., 31.

46 Sustaining U.S. Global Leadership: Priorities for 21st Century Defense (Washington, DC: Department of Defense [DOD], January 2012).

47 National Military Strategy (Washington, DC: The Joint Staff, January 2012).

48 National Defense Authorization Act for Fiscal Year 2015, Public Law 113-291 § 1701, 113th Cong., 2nd sess., December 19, 2014, 128.

49 See Emergency Support Function Annexes, Federal Emergency Management Agency, available at <www.fema.gov/pdf/emergency/nrf/nrf-annexes-all.pdf>.

50 See DOD Innovative Readiness Training Web site, available at <http://irt.defense.gov>.

51 Strategic Plan for FY 2014–2018 (Washington, DC: Department of Agriculture, 2014).

52 JP 3-08, 114.

53 FY 2014–FY 2018 Strategic Plan (Washington, DC: Department of Commerce, 2014), 26.

54 See Uniformed Service Rank Chart, U.S. Public Health Service, available at <www.usphs.gov/docs/pdfs/uniform/Uniformed%20Service%20Rank%20Chart.pdf>.

55 JP 3-08, 117.

56 Ibid.

57 Strategic Plan 2014–2018 (Washington, DC: Department of Energy, March 2014).

58 Quadrennial Energy Review: Energy Transmission, Storage, and Distribution Infrastructure (Washington, DC: Department of Energy, April 2015).

59 Quadrennial Technical Review: An Assessment of Energy Technologies and Research Opportunities (Washington, DC: Department of Energy, September 2015).

60 JP 3-08, 122.

61 Quadrennial Energy Review, 251.

62 Ibid., 3.

63 Strategic Plan for Fiscal Years 2014–2017 (Washington, DC: Department of Treasury, 2014).

64 Ibid., 27.

65 For example, the Departments of Education, Housing and Urban Development, Interior, Justice, Labor, Transportation, and Veteran’s Affairs.

66 JP 3-08, 137, 140.

67 Ibid., 175.

68 Paul N. Stockton, All-Hazards Foreign Response: Lessons Learned from Haiti, Fukushima, and Other Catastrophes (Falls Church, VA: Anser, October 30, 2013).

69 Ibid.

70 See “Operation Unified Response: Support to Haiti Earthquake Relief 2010,” U.S. Southern Command, available at <www.southcom.mil/newsroom/Pages/Operation-Unified-Response-Support-to-Haiti-Earthquake-Relief-2010.aspx>.

71 Independent Review of the U.S. Government Response to the Haiti Earthquake, Final Report (Washington, DC: USAID, March 28, 2011), 54; Gary Cecchine et al., The U.S. Military Response to the 2010 Haiti Earthquake: Considerations for Army Leaders (Washington, DC: RAND, 2013), 27.

72 Kristina Peterson, “Congress Releases Funding to Aid Fight Against Ebola,” Wall Street Journal, October 10, 2014, available at <www.wsj.com/articles/congress-releases-funding-to-aid-fight-against-ebola-1412959345>.

73 U.S. Senate Appropriations Committee, “Statement for the Record Honorable Michael D. Lumpkin, Assistant Secretary of Defense Special Operations and Low-Intensity Conflict,” 113th Congress, November 12, 2014; House Armed Services Committee, “HASC Update: DOD Response to the Ebola Outbreak in West Africa,” October 9, 2014.

74 Government Accountability Office (GAO), Regionally Aligned Forces: DOD Could Enhance Army Brigades’ Efforts in Africa by Improving Activity Coordination and Mission-Specific Preparation, GAO 15-568 (Washington DC: GAO, August 26, 2015), 8.

75 See Haiti Earthquake 2010, Public Health Emergency, available at <www.phe.gov/emergency/news/sitreps/Pages/haitiearthquake.aspx>.

76 JP 3-29, xii.

77 Steve Bowman, Lawrence Kapp, and Amy Belasco, Hurricane Katrina: DOD Disaster Response, RL33095 (Washington, DC: Congressional Research Service, September 19, 2005), 6.

78 “Military Provides Critical Assistance in Aftermath of Massive Storm Sandy,” U.S. Medicine, December 2002, available at <www.usmedicine.com/agencies/department-of-defense-dod/military-provides-critical-assistance-in-aftermath-of-massive-storm-sandy/>.

79 “DOD Provides Hurricane Sandy Response, Relief Update,” November 3, 2002, available at <http://archive.defense.gov/news/newsarticle.aspx?id=118438>.

80 DOD Instruction 2205.02, “Humanitarian Civic Assistance Activities,” Washington, DC, June 23, 2014.

81 See Joint Task Force–Bravo, available at <www.jtfb.southcom.mil>.

82 U.S. Senate Armed Services Committee, “Posture Statement of Admiral Kurt W. Tidd, Commander, United States Southern Command, Before the 114th Congress”; “Infographic: Pacific Partnership and Continuing Promise,” NavalToday.com, available at <http://navaltoday.com/2015/10/02/infographic-pacific-partnership-and-continuing-promise/>; Jeanette Steele, “Mercy Returns from Medical Mission,” San Diego Union-Tribune, September 25, 2015, available at <www.sandiegouniontribune.com/news/2015/sep/25/mercy-returns-10th-pacific-partnership/>.

83 Kellie Moss and Josh Michaud, The U.S. Department of Defense and Global Health: Infectious Disease Efforts (Washington, DC: The Kaiser Family Foundation, October 2013), 7–15; James B. Peake et al., The Defense Department’s Enduring Contributions to Global Health: The Future of the U.S. Army and Navy Overseas Medical Research laboratories (Washington, DC: Center for Strategic and International Studies, June 2011).

84 Foreign Assistance Act of 1973, Public Law 93-189 § 23, 87 Stat, 93rd Cong., 1st sess., December 17, 1973, 727.

85 JP 3-29, GL-7.

86 International Security Assistance and Arms Export Control Act of 1976, Public Law 94-329 § 301, 90 Stat, 94th Cong., 2nd sess. (June 30, 1976), 750.

87 JP 3-20, 37.

88 Aram Roston and David Rohde, “Egyptian Army’s Business Side Blurs Lines of U.S. Military Aid,” New York Times, March 5, 2011.

89 JP 3-20, 37.

90 Foreign Assistance Act of 1961, Public Law 87-195, 87th Cong., 1st sess., September 4, 1961, as Amended Through Public Law 113-76 § 499 (January 17, 2014), 160.

91 Ibid., § 102, 3. See also JP 3-08, 268. DOD defines development assistance as programs, projects, and activities carried out by USAID that improve the lives of the citizens of developing countries while furthering U.S. foreign policy interests in expanding democracy and promoting free market economic growth.

92 Independent Review of the U.S. Government Response to the Haiti Earthquake, Final Report, 71.

93 JP 3-24, Counterinsurgency (Washington, DC: The Joint Staff, November 22, 2013), II-15.

94 Patricia Kime, “Zika Virus: Pentagon Will Relocate At-Risk Family Members,” Military Times, February 1, 2016, available at <www.militarytimes.com/story/military/benefits/health-care/2016/02/01/zika-virus-pentagon-relocate—risk-family-members/79515660/>.

95 James C. McArthur et al., “Interorganizational Cooperation III of III: The Joint Force Perspective,” Joint Force Quarterly 81 (2nd Quarter 2016), 129–139.