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Heterarchy: an Interorganizational Approach to Securing the United States Against a Pandemic Threat

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Heterarchy: an Interorganizational Approach to Securing the United States Against a Pandemic Threat Heterarchy: An Interorganizational Approach to Securing the United States Against a Pandemic Threat By Diane Mars United States public health and security maintained that the potential for a pan- capabilities are vulnerable to the magni- demic to occur is not a matter of if, but tude and complexity of infectious diseas- when (HHS 2012; CDC 2008; Pascoe es. Recently, human cases of a new H7N9 2006; White House 2005). So staving off influenza in China have underscored the catastrophe requires building and main- unpredictability of outbreaks. This article taining a preparedness infrastructure of analyzes the federal government’s role in unparalleled cooperation, vigilance, and addressing an imminent pandemic threat participation. This article focuses on how from an organizational perspective, be- federal departments and agencies in the ginning with the Cabinet Departments executive branch organize their response of Homeland Security (DHS) and Health to pandemic threats. The US Department and Human Services (HHS), which of Homeland Security (DHS) currently jointly lead pandemic planning and re- leads in managing any pandemic threat in sponse. This article recommends that collaboration with the US Department of these departments, their agencies, and Health and Human Services (HHS), which international partners continue building is the medical response lead (Meeks 2005; and maintaining a heterarchy, the most GAO 2011). However, the two distinct optimal interorganizational structure Cabinet departments have been slow to for securing against and responding to a manage their planning (GAO 2011; 2008). pandemic threat. This requires establish- DHS and HHS Secretaries have repeatedly ing clear, yet flexible responsibilities and asserted that the federal government can- shared systems, terminology, and tools. not handle such response efforts without Given a hypothetical scenario in which involving partners across all sectors and a disease is introduced into the United levels of government (Denlinger 2007; States by a potentially infected foreign Napolitano 2009). migrant entering through a maritime This article argues that DHS and port of entry, current protocol and op- HHS should begin to establish and main- erations are promising. However, further tain a heterarchy, which is the optimal heterarchical coordination is necessary interorganizational structure for secur- to appropriately manage all plausible ing against and responding to a pan- scenarios. demic threat. First, this article provides background into the nature of infectious Introduction diseases and viruses. Second, it defines The threat of pandemics poses relevant organizational concepts. Third, a severe risk to the United States given it describes a hypothetical scenario in today’s interconnectivity. Homeland se- which a disease might be introduced into curity and public health officials have the United States by a potentially infected foreign migrant entering through a mari- tions have been critical to public health time port of entry. Finally, it offers recom- and security. Infectious diseases are wide- mendations for how DHS and HHS, and ly acknowledged to be an issue of “shared the agencies contained within them, can concern” (Lemon 2007, xi), not just in operate heterarchically to better address a the purview of the private health indus- future pandemic threat. try or medical academia. National defense against public health emergencies certain- Background: The Magnitude and ly qualifies as a public good according to Complexity of a Pandemic Threat public microeconomic theory. The United States is making incre- Problem mental progress toward integrated plan- Global susceptibility to pandem- ning, detection, mitigation, and response ics stems from a number of complex fac- to pandemic threats (HSC 2007). With ev- tors involving space, time, zoology, and ery confirmed case or outbreak, the issue biology. Populations, and the diseases gains visibility, and national priorities are they carry, move rapidly across land, air, realigned. During the highly pathogenic and sea (Tatem, Rogers, and Hay 2006). avian influenza H5N1 outbreaks in 2005, Transportation systems carrying people, President George W. Bush outlined a first- food, and resources are ubiquitous and ever National Strategy for Pandemic Influ- increasingly transnational (Honigsbaum enza, which called for “the leveraging of all 2012). The sharing of habitats with live- instruments of national power, and coor- stock and other animals has increased the dinated action by all segments of govern- risk of zoonotic1 bacteria and viruses, such ment and society” (HSC 2005, 2). In 2012, as avian or swine influenza (ILRI 2012; President Barack Obama presented a first- WHO, n.d.). Virus vectors, such as those of ever National Strategy for Biosurveillance, migratory birds, and climatic and environ- taking a more expansive approach toward mental changes also heighten urgency for responding to a class of threats, including action (Yu et al. 2009). New viral strains not only emerging infectious diseases and and diseases may evolve more rapidly than pandemics, but also food-borne illnesses a country’s defenses can be sufficiently and bioterror attacks (White House 2012, mobilized. Influenza, in particular, is one ii). The issuance of directives and billions3 of the greatest pandemic threats due its of dollars since the 2003 Severe Acute properties—respiratory routes, high muta- Respiratory Syndrome (SARS) outbreaks tion rates, and high-frequency contagion and 2009 H1N1 swine influenza pandemic (Rodrigue 2013). Given a pandemic’s po- that affected the United States indicates tentially devastating consequences, in- the threat continues to be a national prior- cluding the loss of human life, government ity (White House 2007). In an example of organizations must work with partners Congressional consensus, the Senate and to detect and appropriately manage out- House passed the Pandemic and All-Haz- breaks to minimize morbidity and mortality.2 ards Preparedness Reauthorization Act of 2013 with unanimous and 370–28 votes, Context respectively (Burr 2013; Cohen 2013; US Congress 2013), with the President sign- The Federal Government’s Role ing it into law on March 13, 2013 (HHS The US federal government has 2013). Whatever the decision or decree, an obligation to address and manage the the federal government’s responsibility is response to a pandemic threat. Tradi- to protect and safeguard its citizens and tional governmental roles of policymak- residents, and by extension, those of other ing, delivering services, and ensuring the nation-states—and to do so effectively. continuous performance of essential func- 10.4079/pp.v20i0.11788 Policy Perspectives • 101 102 • Heterarchy: An Interorganizational Approach to Securing the US Against a Pandemic Threat Table 1: Diseases and Viruses that may make Foreign Nationals or Migrants Inadmis- sible to the United States under the Immigration and Nationality Act Category Disease or Virus I. Communicable diseases of public Chancroid, Gonorrhea, Granuloma ingui- health significance nale, Infectious leprosy, Lymphogranu- loma venereum, Active tuberculosis, Infectious syphilis II. Diseases and viruses added by Presi- Cholera, Diphtheria, Infectious tubercu- dential Executive Order losis, Plague, Smallpox, Yellow fever, Vi- ral hemorrhagic fevers (Lassa, Marburg, Ebola, Crimean-Congo, South Ameri- can), Severe acute respiratory syndrome (SARS), Influenza (novel or reemergent) III. Vaccine-preventable diseases of Mumps, Measles, Rubella, Polio, Tetanus, concern Diphtheria, Pertussis, Influenza type B Source: Wasem 2011a, 3–4. Transnational Transmission nated locations where persons, goods, and Though no government could pre- conveyances are screened (GAO 2008), dict the specifics of an emerging pandemic and by their very nature, are conducive to threat with certainty, as President Obama person-to-person transmission. has stated, “the threat will move rapidly A gap or lapse in detecting an and transcend boundaries and borders. So infected person at any of the US’s 329 must our response” (White House 2012, i). ports of entry (CBP 2013; Wasem 2011a) It is imperative that countries stanch any could facilitate widespread infection of influx of infections at internal and external potentially millions at home, and billions points of entry (Wasem 2011a). Under cer- throughout the world. As part of the US tain conditions, developing countries may Code, the Immigration and Nationality be at high risk for prevalence of emerg- Act outlines clear procedures and crite- ing diseases (HSC 2007, 7). Compared to ria for any foreign national who wishes to wealthier and industrialized countries, come into the United States and specifies developing countries may not have the health-related grounds under which one infrastructure, food, manufacturing, or might be deemed inadmissible (Wasem health and safety standards in place to ad- 2011a). The HHS Secretary determines equately prepare or protect the population which diseases trigger inadmissibility at large (Oshitani, Kamigaki, and Suzuki under the Immigration and Nationality 2008). In recent years, disease prevalence Act (Wasem 2011a), as shown in Table 1. has occurred in various countries, from Though the majority of US screenings and Haiti to China (Appendix 1). International admissions occur along a land border and air travel is a commonly accepted, plausi- fall within the jurisdiction of Customs and ble scenario for rapid global dissemination Border Protection (CBP) (Wasem
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