Order Code RS22602
February 8, 2007
Public Health and Medical Preparedness
and Response: Issues in the 110th Congress
Sarah A. Lister
Specialist in Public Health and Epidemiology
Domestic Social Policy Division
Summary
The nation’s systems to detect and respond to public health threats such as
bioterrorism gained renewed interest following the 2001 terrorist attacks. Federal
authorities enacted in comprehensive public health preparedness legislation in 2002
were reauthorized in the 109th Congress, building upon lessons learned from flaws in the
response to Hurricane Katrina and growing concerns about a flu pandemic. The 109th
Congress also completed a statutory reorganization of the Federal Emergency
Management Agency (FEMA). The 110th Congress is likely to study the implementation
of these two laws, and to remain interested in other issues in public health and medical
preparedness and response.
Background and Legislation in the 109th Congress
In December 2006, Congress passed the Pandemic and All-Hazards Preparedness
Act (P.L. 109-417), which extends programs for bioterrorism and other public health
emergency preparedness and response activities within the Department of Health and
Human Services (HHS), and establishes a Biomedical Advanced Research and
Development Authority (BARDA) within HHS for advanced research and development
of medical countermeasures (e.g., diagnostic tests, drugs, vaccines, and other treatments).
In October 2006, Congress passed the Department of Homeland Security Appropriations
Act, 2007 (P.L. 109-295). Title VI of the act incorporated the Post-Katrina Emergency
Management Reform Act of 2006 (the Post-Katrina Act), which reorganizes the
Department of Homeland Security (DHS) and, within it, the Federal Emergency
Management Agency (FEMA). The act also codifies the position of Chief Medical
Officer, with primary responsibility within DHS for medical issues related to natural and
man-made disasters and terrorism.1
1 See CRS Reports RL33589, The Pandemic and All-Hazards Preparedness Act (P.L. 109-417):
Provisions and Changes to Preexisting Law, by Sarah A. Lister and Frank Gottron (hereafter
(continued...)

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The 110th Congress is likely to be keenly interested in implementation of these laws,
and others, that address the readiness of the nation’s public health and medical systems.
This report, which will be updated, discusses key issues in public health and medical
preparedness and response, and cites additional CRS reports and other resources.
Issues in the 110th Congress
Federal Coordination. In planning for public health and medical emergencies,
the roles of the Secretaries of HHS and DHS are not always clear. This was evident in
the response to Hurricane Katrina. Activities in the two departments dovetail in
biodefense research and development, state and local disaster preparedness and response,
domestic and global infectious disease surveillance, the deployment of medical response
assets, mental health counseling for disaster victims, and other areas. The Assistant
Secretary for Preparedness and Response leads HHS’s efforts in public health and medical
preparedness and response. The Chief Medical Officer coordinates comparable activities
in DHS. Certain issues regarding these positions and their respective roles were
addressed in legislation in the 109th Congress.2 The 110th Congress is likely to be
interested in how statutory directives are carried out.
HHS Response Capability. Given the disaster response obligations of HHS,
many question whether the department has the resources — financial, logistical, technical,
and otherwise — to effectively carry out its responsibilities. The 110th 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. Members
of Congress may also consider how HHS funds disaster response activities that are not
reimbursable by FEMA.3 Though the HHS Secretary has authority for a no-year
emergency fund, Congress has not appropriated monies to the fund for many years.
Finally, Congress may consider the permanent authority of the President — acting through
the FEMA Director, in consultation with HHS — to deliver mental health counseling
services to disaster victims, and whether these services are effective and well targeted.4
State Grants for Public Health and Hospital Preparedness. Since
FY2002, Congress has provided about $7 billion in grants to states to strengthen public
health and hospital preparedness for public health threats. Presumably due to national
security concerns, HHS has not published comprehensive or state-specific information
regarding grantees’ performance. Congress has been interested in the management of
1 (...continued)
RL33589), and RL33729, Federal Emergency Management Policy Changes After Hurricane
Katrina: A Summary of Statutory Provisions, Keith Bea, Coordinator (hereafter RL33729).
2 Ibid. See also CRS Reports RL33579, The Public Health and Medical Response to Disasters:
Federal Authority and Funding, by Sarah A. Lister (hereafter RL33579); and RL33738, Gulf
Coast Hurricanes: Addressing Survivors’ Mental Health and Substance Abuse Treatment Needs,
by Ramya Sundararaman, Sarah A. Lister and Erin D. Williams (hereafter RL33738).
3 Pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act (the Stafford
Act, administered by DHS), FEMA may reimburse other federal agencies for activities carried
out in response to presidentially declared emergencies and major disasters.
4 See CRS Reports RL33579 and RL33738.

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these grants, on topics ranging from the relevance of program goals in achieving national
preparedness, to the rigor of fiscal accounting mechanisms, to the balance of federal vs.
state funding shares, to issues of program transparency. The Pandemic and All-Hazards
Preparedness Act extends the programs, adding certain new elements including federal
authority to withhold funds for failure to meet program requirements, a state matching
requirement, and a requirement that the Secretary of HHS publish certain information
about program activities and performance on a federal Internet website available to the
public.5
Biodefense Research and Development. Several federal agencies conduct or
fund research on potential biological weapons, the detection of bioterrorist incidents and
outbreaks of naturally occurring infections, and potential tests and treatments for use on
affected individuals. The two principal agencies involved in civilian research are the
Science and Technology Directorate in DHS, for research to address vulnerabilities and
assess risks to the civilian population and infrastructure related to biological, chemical,
radiological and nuclear threats, and high explosives; and the National Institutes of Health
in HHS, for biomedical research and the development of medical countermeasures.6 The
National Biodefense Analysis and Countermeasures Center (NBACC) was recently
established as the first DHS laboratory specifically focused on biodefense. The mission
of the NBACC program is to understand current and future biological threats, assess
vulnerabilities and determine potential consequences, and provide a national capability
for conducting forensic analysis of evidence from bio-crimes and terrorism.7
Project BioShield. The private sector is reluctant to invest in the development of
drugs, vaccines and other medical countermeasures for threats such as bioterrorism that
may not materialize. To assure the availability of these products, the 108th Congress
launched Project BioShield, a program to encourage the development of chemical,
biological, radiological, and nuclear countermeasures that lack commercial markets. To
address problems with the program’s early implementation, the 109th Congress
incorporated in Title IV of the Pandemic and All-Hazards Preparedness Act a requirement
for the HHS Secretary to develop and make public a strategic plan to guide HHS research,
development and procurement of countermeasures. The act also creates the Biodefense
Advanced Research and Development Authority (BARDA) in HHS, to help implement
the strategic plan, directly support countermeasure development, and facilitate
communication between the government and developers. The 110th Congress is likely to
remain interested in the progress of Project BioShield, and, depending on appropriations,
to oversee the creation and effectiveness of BARDA.8
5 See CRS Report RL33589.
6 Also, the Department of Defense conducts and funds research in, and the development of, the
relevant sciences, technologies, equipment, and systems to ensure that U.S. military forces are
able to detect, protect, treat and remediate against chemical and biological threats.
7 See CRS Report RL32891, The National Biodefense Analysis and Countermeasures Center:
Issues for Congress, by Dana A. Shea.
8 See CRS Reports RS21507, Project BioShield, by Frank Gottron; and RL33589.

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Liability, Compensation, and Intellectual Property Issues. Project
BioShield is intended to address obstacles to countermeasures development associated
with commercial attractiveness. Additional factors may affect the availability of
countermeasures, the willingness of officials to deploy them, or the willingness of citizens
to accept them. In December 2005, Congress passed Department of Defense Emergency
Supplemental Appropriations, 2006 (P.L. 109-148). Division C of the law would
eliminate liability, except in the case of willful misconduct, for manufacturers and others
involved in the production and use of countermeasures, upon a declaration of emergency
by the HHS Secretary. The law also requires the HHS Secretary to develop a mechanism
to compensate those who may be injured by an indemnified countermeasure. Finally,
intellectual property protections may affect the availability of countermeasures by making
them more commercially attractive to developers, or more costly to purchasers, including
governments.9
Workforce Surge Capacity. The health workforce is aging into retirement, yet
is strained by new homeland security duties. Authority for health professions programs
in HHS expired in 2002. These programs are primarily geared toward alleviating
shortages and maldistributions of primary care physicians and nurses. The public health
workforce has, in contrast, received little federal attention until recently. The Pandemic
and All-Hazards Preparedness Act authorizes a loan repayment demonstration project for
individuals who serve in health professional shortage areas, or areas at high risk of a
public health emergency. Efforts to increase the availability of health professionals for
emergency response also include ensuring civil liability protection for volunteer health
professionals, and establishing a system to verify the licenses and credentials of medical
practitioners. While efforts are ongoing among states and on the federal level, a uniform
system for protection of volunteer health professionals does not yet exist.10
Vulnerable Populations. The terror attacks of 2001 and the hurricanes of 2005
showed that some groups of people may be at greater risk of harm, or more in need of
special services, during and following a disaster. These groups may include persons with
disabilities, as defined by the Americans with Disabilities Act. Children and pregnant
women may not be able to safely use the same drugs as the general population during a
bioterrorism incident. Those living in poverty may have fewer options in complying with
a mandatory evacuation order. Individuals with mental health or substance abuse
problems may worsen when faced with disasters, or may lose access to ongoing services.
The Pandemic and All-Hazards Preparedness Act requires the Secretary of HHS, in
various planning activities, to consider at-risk individuals, defined as children, pregnant
women, senior citizens and others who have special needs in the event of a public health
emergency, as determined by the Secretary. The Post-Katrina Act requires the head of
FEMA to appoint a Disability Coordinator, who is charged, among other things, with
9 See CRS Reports RS22327, Pandemic Flu and Medical Biodefense Countermeasure Liability
Limitation, by Henry Cohen; RL32917, Bioterrorism Countermeasure Development: Issues in
Patents and Homeland Security, by Wendy H. Schacht and John R. Thomas; and RL33159,
Influenza Antiviral Drugs and Patent Law Issues, by Brian T. Yeh.
10 See CRS Reports RL32546, Title VII Health Professions Education and Training: Issues in
Reauthorization, by Bernice Reyes-Akinbileje (hereafter RL32546); RS22255, Emergency
Response: Civil Liability of Volunteer Health Professionals, by Kathleen Swendiman and Nathan
Brooks; and RL33589.

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assessing the coordination of emergency management policies and practices for
individuals with disabilities, including training, physical and virtual access, transportation,
media outreach, and general coordination and dissemination of best practices, including
evacuation planning.11
Pandemic Influenza Preparedness. The spread of avian influenza (“bird flu”)
and the human deaths it has caused raise concern that the virus could further evolve and
cause a global human pandemic. To prepare for this threat, the 109th Congress provided
$6.1 billion in emergency supplemental funding for FY2006. Most of this funding
supports an HHS initiative to expand domestic vaccine production capacity. In addition
to oversight of federal spending for pandemic flu, Congress may be interested in (1)
federal coordination of activities to prepare for and respond to a possible pandemic, such
as integrated surveillance for avian and human flu among HHS, DHS, the Departments
of Agriculture and Interior, the State Department, the U.S. Agency for International
Development, and the Defense Department; (2) the impact of avian flu on affected
countries; and (3) the possible effects of a flu pandemic on global trade and commerce.12
Rationing of Scarce Healthcare Resources. Health emergencies often
involve scarcities of healthcare and public health resources, including personnel,
equipment, drugs and vaccines. Prioritizing the use of scarce resources to maximize
benefit requires careful study of scientific and medical evidence, and raises complex legal
and ethical questions that are best considered before emergencies arise.13
Isolation, Quarantine, and Mandatory Vaccination. The response to
communicable disease threats may involve movement restrictions, business and school
closures, compulsory treatments, and other constraints. While state and local governments
have the primary authority over containment measures such as quarantine, isolation, and
mandatory vaccination, a comprehensive response to a public health emergency may
involve overlapping governmental authorities and attendant legal and economic issues.
Constitutional and federal statutory issues may also be raised where individual liberties
are restricted.14
11 See CRS Reports RS22254, The Americans with Disabilities Act and Emergency Preparedness
and Response, by Nancy Lee Jones; RL33589; and RL33729.
12 See CRS Reports RS22576, Pandemic Influenza: Appropriations for Public Health
Preparedness and Response, by Sarah A. Lister; RL33145, Pandemic Influenza: Domestic
Preparedness Efforts, by Sarah A. Lister; RL33219, U.S. and International Responses to the
Global Spread of Avian Flu: Issues for Congress, by Tiaji Salaam-Blyther; RL33795, Avian
Influenza in Poultry and Wild Birds, by Jim Monke and M. Lynne Corn; RL33349, International
Efforts to Control the Spread of the Avian Influenza (H5N1) Virus: Affected Countries’
Responses, Emma Chanlett-Avery, Coordinator; and RS22453, Avian Flu Pandemic: Potential
Impact of Trade Disruptions, by Danielle Langton.
13 For further discussion, see CRS Report RL33381, The Americans with Disabilities Act (ADA):
Allocation of Scarce Medical Resources During a Pandemic, by Nancy Lee Jones.
14 See CRS Reports RL33201, Federal and State Quarantine and Isolation Authority, by
Kathleen S. Swendiman and Jennifer K. Elsea; RL33609, Quarantine and Isolation: Selected
Legal Issues Relating to Employment, by Nancy Lee Jones and Jon O. Shimabukuro; RS22219,
The Americans with Disabilities Act (ADA) Coverage of Contagious Diseases, by Nancy Lee
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Disaster Victims and Healthcare Costs. The 110th Congress may consider
ways to cover healthcare costs for disaster victims. Several bills in the 109th Congress
addressed the healthcare costs of responders and others who were exposed to health
hazards at the World Trade Center following the September 11, 2001 terrorist attack, and
who are now experiencing related health problems.15 Following Hurricane Katrina,
Congress provided $2 billion to cover the state share of Medicaid costs associated with
evacuees and individuals living in declared disaster areas (for states with approved federal
waivers), and to restore access to care in impacted communities. Related issues include
the ongoing healthcare, mental health and substance abuse treatment needs of hurricane
victims, and efforts to rebuild Louisiana’s devastated healthcare infrastructure. Crisis
counseling programs to address the mental health needs of the Hurricane Katrina victims
may be extended. The Louisiana Health Care Redesign Collaborative, a federal, state,
local and private partnership, has been developed to propose options for rebuilding the
healthcare system in southern Louisiana, with an emphasis on strengthened primary care
services, improved access, and fiscal sustainability. The Collaborative will develop a
Medicaid waiver and Medicare demonstration proposal for affected parishes, which will
require HHS approval.16
Expired and Expiring Authorities. The 110th Congress may consider
reauthorization of some expired or expiring preparedness and response programs.17 These
include the Select Agent Program, a program in HHS to regulate certain biological
pathogens and toxins that could be used for bioterrorism. Program authority expires at
the end of FY2007.18 In addition, authority for HHS health professions programs expired
in 2002. These programs have not focused on emergency preparedness and response in
the past, though the last reauthorization in 1998 preceded heightened concerns in this
area.19 Finally, while authority for the Strategic National Stockpile of countermeasures
has been amended several times since the terror attacks of 2001, general program
authority, which expired at the end of FY2006, was not extended.20
14 (...continued)
Jones; and RS21414, Mandatory Vaccinations: Precedent and Current Laws, by Kathleen S.
Swendiman.
15 See, for example, S. 3918, S. 4021, S. 4022, H.R. 6046 and H.R. 6124. See also HHS, “World
Trade Center Health Resources,” at [http://www.hhs.gov/wtc/].
16 See the Louisiana Healthcare Redesign Collaborative charter at [http://www.hhs.gov/
louisianahealth/collaborative/charter.html]. See also CRS Reports RL33579; RL33083,
Hurricane Katrina: Medicaid Issues, by Evelyne P. Baumrucker, April Grady, Jean Hearne,
Elicia J. Herz, Richard Rimkunas, Julie Stone, and Karen Tritz; and RL33738.
17 See Congressional Budget Office, “Unauthorized Appropriations and Expiring Authorizations,”
Jan. 2007, at [http://www.cbo.gov/publications/bysubject.cfm?cat=6].
18 42 U.S.C. § 262a. See the CDC Select Agent Program page at [http://www.cdc.gov/od/sap/].
19 See CRS Report RL32546.
20 See CRS Report RL33589.

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