COVID-19: HHS Should Clarify Agency Roles for Emergency Return of U.S. Citizens during a Pandemic

What GAO Found

At the beginning of the COVID-19 pandemic, the U.S. returned, or repatriated, about 1,100 U.S. citizens from abroad and quarantined them domestically to prevent the spread of COVID-19. The Department of Health and Human Services (HHS) experienced coordination and safety issues that put repatriates, HHS personnel, and nearby communities at risk. This occurred because HHS component agencies—the Administration for Children and Families, the Office of the Assistant Secretary for Preparedness and Response, and the Centers for Disease Control and Prevention—did not follow plans or guidance delineating their roles and responsibilities for repatriating individuals during a pandemic—an event these agencies had never experienced. While they had general repatriation plans, there was disagreement as to whether the effort was in fact a repatriation. This led to fundamental problems for HHS agencies and their federal partners, including at the March Air Reserve Base quarantine facility in California where the first repatriated individuals were quarantined prior to widespread transmission of COVID-19 in the U.S. These problems included the following:

  • Lack of clarity as to which agency was in charge when the first repatriation flight from Wuhan, China, arrived at the quarantine facility, which caused confusion among the HHS component agencies.
  • Coordination issues among HHS component agencies resulted in component agencies operating independently of each other, and led to frustration and complications.
  • HHS’s delay in issuing its federal quarantine order, during which time a repatriate tried to leave the quarantine facility.
  • HHS personnel’s inconsistent use of personal protective equipment (PPE), and HHS officials’ disagreement on which agency was responsible for managing infection prevention and control. An HHS official also directed personnel to remove their PPE as it created “bad optics,” according to an HHS report that examined the repatriation effort.

The National Response Framework, a guide to how the U.S. responds to disasters and emergencies, instructs agencies to understand their respective roles and responsibilities, know what plans apply, and develop appropriate guidance for emergency responses. Until HHS revises or develops new plans that clarify agency roles and responsibilities during a repatriation in response to a pandemic, it will be unable to prevent the coordination and health and safety issues it experienced during the COVID-19 repatriation response in future pandemic emergencies.

HHS also did not include repatriation in its pandemic planning exercises. As a result, agencies lacked experience deploying together to test repatriation plans during a pandemic, which contributed to serious coordination issues. GAO has previously reported that exercises play an important role in preparing for an incident by providing opportunities to test response plans and assess the clarity of roles and responsibilities. Until HHS conducts such exercises, it will be unable to test its repatriation plans during a pandemic and identify areas for improvement.

Why GAO Did This Study

HHS provides temporary assistance to U.S. citizens repatriated by the Department of State (State) from a foreign country because of destitution, illness, threat of war, or similar crises through the U.S. Repatriation Program. In January and February 2020, HHS assisted State in repatriating individuals from Wuhan, China, and the Diamond Princess cruise ship in Yokohama, Japan, to the U.S. HHS quarantined repatriates at five Department of Defense (DOD) installations to ensure they did not infect others with COVID-19.

GAO was asked to examine HHS’s COVID-19 repatriation efforts to ensure the health and safety of those involved in the response. This report examines HHS’s coordination and management of its COVID-19 repatriation response.

GAO reviewed relevant documentation from HHS, State, and DOD related to repatriation planning, including documentation on pandemic planning exercises. GAO also interviewed officials from HHS, State, and DOD.

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  • Science & Tech Spotlight: Consumer Electronics Recycling
    In U.S GAO News
    Why This Matters Consumer electronics contain critical materials whose supplies are limited, including gold, platinum, and rare earth metals. Domestic recycling of consumer electronics could extend the supply and reduce the current U.S. reliance on imports. New technologies are becoming available, but electronics recycling is complex and faces challenges, such as narrow profit margins. The Technology What is it? Recycling of consumer electronics—including smartphones, televisions, and computers—generally involves separating high-value metals from plastics and other low-value materials. Precious metals and rare earth metals are the economic driving force for consumer electronic recycling technology. These metals have high market values and limited supplies, and they can be reused across many industries, including the defense and energy sectors. Consumer electronic devices can also contain personally identifiable information (PII), including medical and financial data, which could be improperly disclosed if they are not destroyed prior to recycling. According to a study of selected consumer electronics, about 2.8 million tons were disposed of in the U.S. in 2017, of which about 36 percent was recycled. Figure 1. Selected valuable, hazardous, and digital materials contained within consumer electronics that can be recovered, disposed, or destroyed There is no federal standard requiring consumer electronics recycling. Some states have enacted electronics recycling laws requiring electronics producers to pay fees or contract with businesses to ensure electronic waste is collected for recycling. The U.S. recycles electronics domestically and also exports electronics for recycling abroad. How does it work? The high concentration of valuable material in certain consumer electronics is key to the economic viability of recycling these products. Cell phones, as one example, have more precious metal by weight than raw ore does. According to the EPA, 35,274 pounds of copper, 772 pounds of silver, and 75 pounds of gold can be recovered from a million recycled cell phones. Based on commodity market prices on August 12, 2020, these weights of metals are worth approximately $100,000, $290,000, and $2.1 million for copper, silver, and gold, respectively. In contrast, cathode ray tube (CRT) displays in older televisions and computer monitors have little recycling value, but they contain leaded glass and may be considered hazardous waste. In addition, recovery of certain valuable materials from consumer electronics is limited due to the high costs of technology and processing. Electronics recycling companies disassemble devices by shredding, which also destroys PII, or by hand. These companies then separate valuable materials for reuse (including gold, silver, platinum, and rare earth metals) from toxic materials for disposal (including brominated materials and lead). Traditional methods include burning to remove non-metal parts and separation using strong acids. New separation technologies are being used or piloted to recover precious and rare earth metals. For example, robotic disassembly uses machine learning and computer vision to more rapidly pick and sort items. Another new technology uses ultrasound to speed up the chemical removal of gold from cell phone SIM cards. Figure 2. Emerging separation technologies for recycled electronics Other technologies are emerging, like biometallurgy, which uses microorganisms to separate high-value metals from other materials, such as plastics, glass, and glue. For example, naturally occurring bacteria can oxidize gold in acidic solutions, making it soluble and thus easier to separate from other materials. Other advanced techniques, such as magnetic or electrochemical separation, are showing promise in the laboratory with existing technology. For example, in one study, researchers used ultrasound to dissolve nickel and gold within a SIM card. They then used a magnetic field to separate the dissolved nickel, which is magnetic, from the gold, which is not. Similarly, other techniques use electric fields to separate dissolved metals based on their weight and electric charge. How mature is it? Recycling technology is well established for some traditional single-stream processes, such as aluminum recycling. However, electronic devices are more complex and require disassembly and separation. At least one consumer electronics manufacturer is piloting robotic disassembly for its products. Emerging separation technologies such as ultrasound have come to market in the past decade and are being used. Manual disassembly and shredding are decades old. Biometallurgy is being tested in pilot plants, and new microorganisms are being developed in laboratories to treat electronic waste. Opportunities Increase supply and reduce imports. Recycling could increase the domestic supply of precious and rare earth metals and reduce the current U.S. reliance on overseas sources. Grow the green economy. Developing advanced recycling technologies could promote domestic business and employment. Reduce hazardous practices. A significant amount of recycling currently occurs in the developing world, where methods include open-pit burning. New technology could reduce the use of such methods, which are hazardous to the environment and human health. Lessen environmental impacts. Developing advanced recycling technologies could reduce the environmental impacts of raw ore mining and landfill disposal of hazardous materials such as lead and brominated materials. Challenges Market challenges. Markets for recovered materials may be limited, and the value of recovered materials may not be enough to cover the costs of equipment for collection, sorting, disassembly, and separation. Secure destruction of personal information. Many electronic devices contain PII. Shredding them may effectively destroy PII but may also make high-value material harder to recover. Counterfeit electronic parts. Exported used electronics may serve as a source of counterfeit electronic parts, which, as GAO previously reported, could disrupt parts of the Department of Defense supply chain and threaten the reliability of weapons systems. (See GAO-16-236, linked below.) Rapid technological development. As consumer electronics made with new materials get smaller, new technologies for separation may be needed to recycle valuable materials. Policy Context and Questions With the volume of electronic waste expected to grow, questions include: How can programs to support technological innovation, economic development, and advanced manufacturing be leveraged to promote a more robust domestic electronics recycling industry? What efforts can the federal government, states, and others make to incentivize recycling rather than disposal? What are the potential benefits and challenges of such policies? What strategies can the public and private sectors implement to address the risk that exports of used electronics will contribute to unsafe recycling practices, disclosure of PII, and counterfeit electronics? How can reductions in exports bolster job growth? For more information, contact Karen Howard at (202) 512-6888 or HowardK@gao.gov.
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  • Puerto Rico: Perspectives on the Potential to Expand Air Cargo Operations
    In U.S GAO News
    Cargo was flown by air between more than 97 countries within the selected regions of Africa, Europe, Latin America, and the U.S. that may affect air cargo expansion in Puerto Rico. However, according to Department of Transportation (DOT) and European Union data, most international air cargo transportation was concentrated at a handful of countries and at airports in these regions. For example, four countries in Europe accounted for 72 percent of the U.S.-European Union air cargo transported, by weight. Likewise for airports, Miami International Airport accounted for 70 percent of air cargo transported between the U.S. and Latin America. Worldwide, cargo-only carriers transported on average 13.8 billion pounds of air cargo to and from the U.S. from 2016 through 2018. Of that cargo, two of the selected regions—Latin America and Europe—when combined accounted for 46 percent. Air Cargo Transported by Cargo-Only Airlines between the U.S. and Global Regions, Average Weight in Millions of Pounds, 2016 through 2018 Based on interviews with industry stakeholders and studies reviewed. GAO identified four factors that are generally associated with an airport's ability to attract air cargo traffic: (1) an airport's geographical location; (2) its proximity to transportation networks; (3) its supporting airport infrastructure and resources; and (4) the governmental and regulatory environments. For example, an airport located near businesses that generate large volumes of both inbound and outbound cargo that could be transported by air may be an important geographic factor for air carriers. Puerto Rican government and industry stakeholders GAO spoke with said that increased air cargo would benefit its airports and lead to positive effects on the Puerto Rican economy. For example, officials noted that expansion of air cargo operations could increase the use of underutilized airports and create opportunities for existing industry—such as the pharmaceutical, medical device, and aerospace industries—and help develop new ones. Puerto Rican and industry stakeholders had varying perspectives on the potential for Puerto Rico's expanding its air cargo operations. For example, some stakeholders said Puerto Rico's geographic location may allow it to serve as a refueling and cargo distribution point, particularly for flights between Europe and Latin America, while others said the island may be too close to some Latin American destinations to serve that purpose. Whether and to what extent Puerto Rico can increase air cargo operations depends on how air carriers weigh the various factors discussed above. Puerto Rico's economy has been in decline for much of the last 15 years and was devastated by hurricanes in 2017. Puerto Rico has sought to increase air cargo and passenger traffic at its international airports as a means to bolster and diversify its economy. Specifically, Puerto Rico seeks to serve as a transshipment point for transferring cargo between air carriers flying from Europe to Latin America. Air cargo, whether carried in the holds of passenger aircraft or by cargo-only aircraft, is an important component of global trade. The FAA Reauthorization Act of 2018 includes a provision for GAO to study the international air cargo transportation services among the United States and the African, Latin American, and European regions and the potential expansion of air cargo operations in Puerto Rico. This report addresses (1) what is known about air cargo operations between these world regions; (2) factors affecting the development of air cargo markets; and (3) Puerto Rican officials' and selected industry stakeholders' views on the economic effect and potential of expanding air cargo operations in Puerto Rico. GAO analyzed DOT and European air cargo data for flights between the U.S. and the selected regions for 2016 through 2018 (the latest available data). GAO also interviewed officials from DOT, and stakeholders from Puerto Rico and the air-cargo industry, selected based on prior GAO work and stakeholder mission. For more information, contact Heather Krause at (202) 512-2834 or krauseh@gao.gov.
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  • VA Disability Exams: Actions Needed to Improve Program Management
    In U.S GAO News
    What GAO Found In recent years, the Department of Veterans Affairs (VA) has significantly expanded the Veterans Benefits Administration's (VBA) use of contractors to perform disability medical exams instead of relying on Veterans Health Administration (VHA) medical centers. According to VBA officials, VA's policy is to continue using contractors for most exams. GAO previously identified sound practices agencies can use to plan for significant programmatic changes. However, VBA has not applied several of these practices to its plans for allocating workloads among its contractors and VHA medical centers. For example, VBA has not assessed potential risks to capacity and exam quality in allocating the bulk of exams to contractors. Employing such practices could help VBA identify potential risks stemming from this long-term program change and better plan for addressing future workload needs. Percent of Disability Exams Performed by VBA Contractors and by VHA Medical Centers, Fiscal Years 2017-2021 Over time, VA has also permitted contractors to complete exams for more complex disability claims—such as Gulf War Illness—according to VBA officials, but VBA does not conduct targeted reviews specifically to assess the quality of the exam reports completed for these exams. VBA data show that exam reports for selected complex claims were returned to examiners for correction or clarification at about twice the rate that exam reports were returned overall. Disability medical examiners told GAO that these types of exams can be challenging. Without specifically assessing how well contractors perform on exams for complex claims, VBA is missing an opportunity to identify actions that could help ensure veterans receive high quality exams and that exam reports are completed correctly. Why GAO Did This Study This testimony summarizes the information contained in GAO's March 2021 report, entitled VA Disability Exams: Better Planning Needed as Use of Contracted Examiners Continues to Grow (GAO-21-444T). This testimony also builds upon prior GAO reporting on VBA's contract exam program in October 2018 (GAO-19-13).
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  • Nuclear Weapons: NNSA Plans to Modernize Critical Depleted Uranium Capabilities and Improve Program Management
    In U.S GAO News
    The Department of Energy's (DOE) National Nuclear Security Administration (NNSA) is taking steps to establish a new supply of high-purity depleted uranium (DU) to modernize the nuclear weapons stockpile. DU for fabrication of weapons components must be in high-purity metal form. Producing DU metal generally involves first converting a byproduct of uranium enrichment, known as “tails,” into a salt “feedstock,” which is then converted into metal. (See figure.) To reestablish a supply of feedstock, NNSA plans to install conversion equipment in an existing facility at DOE's Portsmouth site in Ohio. DOE initially estimated costs of $12 million to $18 million to design and install the equipment, with operations beginning in fiscal year 2022. However, in March 2020, NNSA requested an increase in conversion capacity, and an updated proposal in July 2020 estimated costs of $38 million to $48 million and a slight delay to the start of operations. NNSA plans to convert the feedstock into DU metal using a commercial vendor at a cost of about $27 million annually. Conversion of a Byproduct of Uranium Enrichment into Metal NNSA is also taking steps to reestablish and modernize DU component manufacturing capabilities, but it risks delays that could affect the timelines of nuclear stockpile modernization programs, according to officials. NNSA has reestablished processes for manufacturing some DU components but not for components made with a DU-niobium alloy, a material for which NNSA has no alternative. Thus, restarting the alloying process—a complicated, resource-intensive process that has not been done in over a decade—is NNSA's top priority for DU and presents a very high risk to timely supply of components for certain nuclear stockpile modernization programs, according to NNSA documents and officials. NNSA is also developing more efficient manufacturing technologies, in part because the current alloyed component process wastes a very high percentage of the materials and NNSA cannot recycle the waste. For its DU activities, NNSA has requested an increase in funding from about $61 million in fiscal year 2020 to about $131 million in fiscal year 2021. Until recently, NNSA had not managed DU activities as a coherent program in a manner fully consistent with NNSA program management policies. Since October 2019, however, NNSA has taken actions to improve program management. For example, NNSA has consolidated management and funding sources for DU activities under a new office and DU Modernization program with the goal of better coordinating across the nuclear security enterprise. Further, NNSA appointed two dedicated Federal Program Managers to gather and organize information for required program management and planning documents. High-purity DU is an important strategic material for ongoing and planned modernizations of the nation's nuclear weapons stockpile. However, according to NNSA estimates, NNSA has a very limited supply of DU feedstock, and its current supply of DU metal will be exhausted in the late 2020s. NNSA also does not have the full range of capabilities needed to manufacture DU into weapon components needed for modernizing the stockpile. GAO has previously reported that NNSA has experienced challenges in restarting some technical manufacturing processes. A Senate committee report accompanying a bill for the National Defense Authorization Act for Fiscal Year 2017 included a provision for GAO to examine NNSA's management of DU for nuclear stockpile modernization. GAO's report examines (1) the status of NNSA's efforts to obtain the necessary quantities of DU to meet stockpile modernization requirements; (2) the status of NNSA efforts to develop DU component manufacturing capabilities to meet stockpile modernization requirements; and (3) the extent to which NNSA is managing DU activities as a program, consistent with agency policy. GAO reviewed relevant agency documents; interviewed NNSA officials and contractor representatives; and conducted site visits at headquarters and at research, development, and production locations. For more information, contact Allison Bawden at (202) 512-3841 or bawdena@gao.gov.
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