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White House Releases HSPD 21: National Strategy for Public Health and Medical Preparedness

By Crystal Franco*, October 19, 2007

On October 18, 2007, the White House released Homeland Security Presidential Directive 21 (HSPD 21) establishing a “National Strategy for Public Health and Medical Preparedness.”  HSPD 21 builds upon “key principles” from previous White House releases including the National Strategy for Homeland Security (2007), the National Strategy to Combat Weapons of Mass Destruction (2002), and Biodefense for the 21st Century.1

The directive specifically addresses preparedness for “catastrophic health events,” both natural and man-made, which “result in a number of ill or injured persons sufficient to overwhelm the capabilities of immediate local and regional emergency response and health care systems.” Catastrophic health events include, but are not limited to terrorist attacks with a biological weapon, nuclear weapon, or other weapon of mass destruction (WMD); a 1918-like influenza pandemic; and “calamitous meteorological or geological event[s],” any of which could result in tens to hundreds of thousands of casualties (or more) and have the potential for great economic destabilization. The directive emphasizes that catastrophic health events “threaten our national security;” therefore, the U.S. needs to have a “strategic vision that will enable a level of public health and medical preparedness sufficient to address a range of possible disasters.”

HSPD 21 defines the 4 most critical components of public health and medical preparedness as:

  1. Biosurveillance: The U.S. must establish a biosurveillance capability, with connections to international disease surveillance systems, that can provide “early warning” of a bio-attack or naturally occurring outbreak, and can provide ongoing “near real-time” information about an outbreak as it unfolds. This system should be designed to provide a national “common operating picture” and better situational awareness for state, local, and federal officials, as well as for public and private sector healthcare providers.

  2. Countermeasure Distribution: Recognizing that state and local government authorities have the “primary responsibility” for distribution of medical countermeasures (e.g., vaccines, antibiotics, etc.) to their populations in an emergency, the federal government must work with state and local entities to share best practices and formulate useful templates for mass distribution that can be adapted by different locations.

  3. Mass Casualty Care: The nation must develop a “disaster medical capability” that will be “(1) rapid, (2) flexible, (3) scalable, (4) sustainable, (5) exhaustive (drawing upon all national resources), (6) comprehensive (addressing needs from acute to chronic care and including mental health and special needs populations), (7) integrated and coordinated, and (8) appropriate (delivering the correct treatment in the most ethical manner with available capabilities).” This capability will need to be different from “day-to-day” public health and medical operations which “cannot meet the needs created by a catastrophic health event.”

  4. Community Resilience: The federal government must formulate a plan for “promoting community public health and medical preparedness to assist State and local authorities in building resilient communities.” By implementing programs where community organizations, leaders, and citizens are “educated regarding threats and are empowered to mitigate their own risk, where they are practiced in responding to events…have social networks to fall back upon, and where they have familiarity with local public health and medical systems, there will be community resilience that will significantly attenuate the requirement for additional assistance.”

HSPD 21 includes a number of specific “implementation actions” for public health and medical preparedness:

  1. Biosurveillance: The Secretary of Health and Human Services (HHS) shall create an “operational national epidemiologic surveillance system for human health” implementation plan with specific “milestones for the system.” This will be done in part in consultation with an Epidemiologic Surveillance Federal Advisory Committee including state and local government public health officials, and private sector healthcare representatives, and is to be established within 180 days following the release of HSPD 21.

  2. Countermeasure Distribution: The Secretary of HHS will work with federal, state, and local government and private sector representatives to develop, test, and evaluate templates for countermeasure distribution. An initial template is to be published 270 days following the release of HSPD 21. HHS will also work to establish performance measures for state and local countermeasures distribution programs and develop a process for gathering performance data and assessing readiness. Metrics should be set and data being gathered within 180 days following the release of the directive. The federal government is required to plan for federal countermeasures distribution assistance to states and localities in the event that they are overwhelmed during a catastrophe. HHS must also review the contents of the Strategic National Stockpile (SNS), and share “relevant information regarding the contents of the SNS with federal, state, and local government health officers with appropriate clearances and a need to know.”

  3. Mass Casualty Care: The Secretary of HHS must engage federal, state, local, academic, healthcare and other stakeholders to “provide feedback” on a review of the National Disaster Medical System and national medical surge capacity. HHS will also lead the creation of an interagency report on “barriers to public health and medical preparedness and response…that can be eliminated by regulatory or legislative action,” to be delivered within 120 days; and HHS will coordinate across agencies to establish a Federal Advisory Committee for Disaster Mental Health within 180 days of the directive’s release.

  4. Community Resilience: The Secretary of HHS will coordinate across agencies to ensure that core public health and medical training addressed ways to “improve individual, family, and institutional public health and medical preparedness, enhance private citizen opportunities for contributions to local, regional, and national preparedness and response, and build resilient communities.” The Secretary of HHS (in coordination with other agency secretaries) is to submit a plan for promoting “comprehensive community preparedness” to the President within 270 days of the release of HSPD 21.

The directive also addresses the issues of “risk awareness” of catastrophic health events, and the need for further integration of public health and medical disaster preparedness and response education and training for federal, state, and local government officials as well as for members of the private sector.

In order to help ensure implementation, HSPD 21 establishes the Public Health and Medical Preparedness Task Force consisting of the Secretaries of HHS, Department of Homeland Security, Department of Defense, State, Agriculture, Commerce, Labor, Transportation, and Veterans Affairs; Directors of the Office of Management and Budget, and National Intelligence; and the Attorney General. The task force will submit an implementation plan to the President within 180 days of the release of the directive and will report annually on the status of the implementation plan.

*Crystal Franco is an Analyst with the Center for Biosecurity and a Co-Managing Editor of the Biosecurity Briefing, where this article also appeared.


  1. Homeland Security Presidential Directive/HSPD-21 [news release]. Washington, DC: The White House; October 18, 2007. Accessed October 19, 2007.